Integrating Advanced Practice Providers (APPs) Into Practice

Both advanced practice nurses/nurse practitioners (APNs/NPs) and physician assistants (PAs) are advanced practice providers (APPs). We include a description of each below.

Advanced Practice Nurse/Nurse Practitioner (APN/NP) Description

NPs (Nurse Practitioners) are clinicians who have completed a master's or doctoral degree program with advanced clinical training beyond that of their initial professional registered nurse (RN) program. NPs must graduate from an accredited program and pass a national certification exam within their specialty of practice. (Specialty areas most applicable to the breast care setting would include Family Health, Oncology, and Women's Health.)

They work autonomously and in collaboration with health care professionals providing a full range of primary, acute, and specialty services (dependent upon their certification specialty). NPs can order diagnostic imaging, diagnose, and treat illness, prescribe medication, and educate on diseases prevention/health promotion. NPs practice under the rules and regulations of the state in which they are licensed. View practice information by state (aanp.org).

Scope of practice falls into 3 main categories, or levels, of practice authority:

1. Full Practice Authority—in full practice authority states, nurse practitioners can perform the full scope of practice without a supervising or collaborating physician.
2. Reduced Practice Authority—in reduced practice states, nurse practitioners can perform some of their scope of practice without physician supervision. These restrictions typically involve operating their own practices or prescribing certain types of medications.
3. Restricted Practice Authority—in restricted practice states, nurse practitioners must work under the supervision of a physician for all of their scope of practice. While they may have extensive autonomy in some nurse practitioner functions, they are not acting as independent practitioners.

Physician Assistant (PA) Description

PAs (physician assistants) are licensed clinicians who practice medicine in multiple specialties. PAs are educated at a master's degree level. PAs must graduate from an accredited program after completing a broad, generalist medical education with clinical rotations in inpatient, outpatient, surgical, and emergency department settings. PAs must pass a certification exam assessing medical and surgical knowledge. They are then able to practice in any medical specialty. To maintain certification, 100 hours of CME is required every 2 years, and there is a recertification exam every 10 years.

PAs work interdependently with physicians. They are licensed to diagnose and treat illness, order diagnostic imaging, and prescribe medication for patients. PAs work under a medical model (emphasizing pathology, biology, assessment, diagnosis, and treatment of a symptom or disease). Scope of practice varies by state (all information below is from the AMA):

• PAs are authorized to prescribe Schedule II-V medication in most states (44)
• PAs lack the authority to prescribe Schedule II medication in 6 states (AL, AR, GA, HI, IA, WV)
• PAs lack the authority to prescribe legend drugs in 1 state (KY)
• In 47 states, PAs are supervised by physicians
• In 2 states, PAs are subject to collaborative agreements with physicians (AK, IL)
• 2 states allow for alternate arrangements: New Mexico calls for supervision for PAs with less than 3 years of clinical experience, and for specialty care PAs, and in Michigan, PAs work under a participating physician
• In most states (43), PAs are regulated by the medical board. However, in 8 states (AZ, CA, IA, MA, MI, RI, TN, UT), PAs have a separate and independent regulatory board
• In most states (47), PA scope of practice is determined with the supervising/collaborating physician at the practice site From the AMA Advocacy Resource Center

Job/Role Descriptions in a Breast Practice

There is substantial crossover in the role of Nurse Practitioners and Physician Assistants; however, the oversight and level of physician involvement can vary between states as well as between institutions. An individual's previous professional experiences will understandably play a role in the care of a patient. Both NP's and PA's have obtained master's degrees but within both education paths, there can be variance in clinical experience. PAs are licensed by the medical board and must have a collaborating physician but can also work autonomously, NPs are licensed by their state board and in many states are independent practitioners, however scope can vary from state to state.

Within a breast center, NPs and PAs can work independently, supportively or a combination of the 2 roles. Descriptions of these roles are below:

Independent

• Assesses and manages treatment for patients of all ages for a variety of breast conditions including clinic consultations and in-office procedures.
• Orders and interprets laboratory and imaging data
• Manages care for patients with history of breast cancer in all stages including initial diagnosis, post-surgical, and in all phases of survivorship.
• Initiates testing and further work up in patients recently diagnosed with breast cancer
• Assesses benign breast disease and breast infections
• Performs pre and post op assessment in patients undergoing surgical procedures
• Examples of in-office procedures:
• Aspiration
• Incision and drainage
• Punch biopsy
• Superficial excisional biopsies (including wound closure) (ie, sebaceous cyst, skin tags, irritated nevus, lipomas)
• Palpation guided core biopsies (dependent on state and institutional policies)
• Port removals (dependent on state and institutional policies)
• US assessment, seroma aspiration, cyst aspirations, intralesional injections (ie, injection of Kenalog into bx proven granulomatous mastitis), monitor benign lesions such as fibroadenomas, ultrasound-guided biopsies (dependent on state and institutional policies)

• Manages patients within the high-risk clinic
• Follows patients with family history or personal history of high-risk lesions
• Assesses individual and family risks for a variety of inherited genetic disorders, generates 3 generation pedigrees, orders and interprets genetic test findings.
• Determines short- and long-term risk of development of breast cancer
• Creates personalized surveillance plans for patients based on their risk of breast cancer
• Counsels women on breast cancer risk reduction measures including surgical intervention, lifestyle alterations, and chemoprevention
• Follows patients on chemoprevention
• Manages patients in survivorship
• Management of cancer surveillance and adjuvant therapies
• Connecting patients to resources regarding ongoing management of side effects of cancer treatment (ie, PT/OT, lymphedema, nutrition, sexual health, counseling)/li>
• Works with other members of the oncology service line to provide comprehensive team care for patients
• Prevention of recurrence, secondary cancers, and late effects
• Screening – recurrence & new primaries (radiation-induced sarcomas, chemotherapy-induced leukemias), order and review imaging
• Healthy Lifestyles
• Physical Activity
• Nutrition and weight management
• Supplement Use
• Familial/Genetic Risk Assessment
• Immunizations and infections
• Surveillance for disease progression, secondary cancers, and late effects
• Cardiovascular disease
• Anthracycline-Induced Cardiac Toxicity
• Anxiety, depression, trauma, and distress
• Cognitive Function
• Fatigue
• Lymphedema
• Pain
• Hormone-related symptoms
• Sexual function
• Sleep disorders
• Intervention to control consequences of cancer treatments, provide updates, foster adherence

Collaborative

• Works alongside breast surgeon as first assist in the operating room
• Works alongside the breast surgeon in the clinic
• Writes orders, rounds, and discharges patients after surgical procedures/admission
• Follow up on ordered medical tests and imaging
• Assists in data collection for research studies

Other FAQs

What are the advantages of a bringing in an APP?

1. APPs can offload work for you that can make you more efficient-such as managing phone calls, calling results, the inbox, precerts, seeing established patients, seeing post-op patients, etc.
2. APPs can help increase access in your clinics by either seeing new patients or offloading your established patients so you can see more new patients
3. APPs can provide a service that you may not have as much time for such as seeing high-risk patients, patients with benign breast problems, established cancer patients for long term follow up, etc.

How are APPs funded?

1. APPs can either be paid for by your health system or you pay their salary (or perhaps a combination of these 2 models). Since APPs can bill for their work they can recuperate and offset their salary with clinic visits, etc.
2. If your health system pays for them you will have to see who gets credit for their RVUs and collections-the health system or you?
3. If you have to pay their salary, there are 2 ways to pay their salary:
1. The APP's independent billings (in clinic, OR)
2. Your salary covers their salary, if they are working alongside you like a resident, then feasibly you are able to see more patients and bring in more collections to cover their salary
3. Combination of i and ii above

How can APPs bill for their visits?

1. "Incident to billing"
1. APPs can use for established patients only
2. APP sees the patient independently but bills under the MD name
3. The MD has to be in the same physical location as the APP
4. Medicare will only cover 85% of the MD charge for these types of visits
2. Split/share billing:
1. Both the APP and MD see the patient
2. APP and MD both document time spent with pt
3. MD will bill for total time spent with the patient (MD + APP)
4. MD will collect all the RVUs
5. May apply more for the inpatient setting
6. Cannot be used for new consults
7. Rules may vary by state
3. APP independent billing:
1. APP sees the patient on their own
2. APP bills for the visit under their name
3. APP collects all the RVUs for these visits
4. Visit is covered by Medicare at 85% of the MD rate

Can APPs work in the operating room?

1. If an APP is listed as an “assist in surgery” for billing then the operative note needs to include a statement justifying their presence, how they helped with the case and that a resident/fellow was not available. APPs collect approximately 13% of what a MD collects.
2. APPs cannot bill as a first assist if there is a resident or fellow scrubbed on the case.
3. Mastectomy cases are usually billable, but breast conserving surgery and sentinel node biopsy cases may not always be billable unless you document medical necessity. Many insurance carriers will not reimburse for breast conserving surgery and sentinel node biopsy cases-it is recommended to check with your practice manager about what cases are billable.

Can APPs see new patients? Established patients?

1. APNs and PAs can see both new and established patients. They can bill for these visits but can only get 85% of the MD reimbursement (Medicare) if they are seeing these patients on their own.

Can APPs perform office procedures?

1. Yes, APNs and PAs can perform office procedures (see above under job description)
2. Which procedures depends on your health system and privileges granted by the hospital and also what your group deems is okay for them to do

APP: Sample Job Interview Questions

Specific to Breast Specialty

1. How many patients are you comfortable seeing in the clinic per day?
2. Do you have experience with breast exams?
3. Do you have experience seeing patients independently?
4. Are you used to working collaboratively with other departments and disciplines (for example, radiology, pathology, medical oncology, etc)
5. Do you have any experience working in the operating room?
6. What experience do you have doing any breast procedures such as biopsies, incision and drainage procedures, etc?
7. Are you comfortable with wound care issues?
8. What acuity level do you feel comfortable with? In hospital or only outpatient?
9. Are you interested in any breast specific certifications or CME (you will have to see if your institution will cover these certifications or CME)?

General Questions

1. What are your expectations from this position?
2. What are your expectations from the onboarding process?
3. Tell me about yourself and why you decided to become an APP
4. Tell me about your experience in the past within the field of breast surgery (past jobs?)
5. Tell me why you are interested in the field of breast surgery
6. Where do you see yourself in 5 years?
7. What is your greatest strength? What is your greatest weakness?
8. How do you view your role within our team?

Sample Performa for APN

SBAR: Situation, Background, Assessment, Recommendation

Situation: The Advanced Practice Clinician (APC) position is essential to support the Breast Center to increase volume and increase efficiency of the physicians. This model has been successful with other surgical specialties such as Trauma, Plastic Surgery, Gynecologic Oncology and ENT.

Highly trained assistants can shorten procedure time for the surgeons, allow surgeons to see more patients, and see non-surgical patients, thus allowing the surgeon to focus on seeing more surgical candidates. This position can generate additional volume of patients in the Breast Center by initiating a high-risk program, thus bringing in more patients and generating more imaging exams.

Background: Currently two busy breast surgeons seeing surgical patients in the breast center leaves little time to see new high-risk patients and patients with benign breast complaints. This is an opportunity loss which could be captured by an advanced practitioner.

Women at increased risk for developing breast cancer require additional screening compared to average risk women. At the                      Breast Center, approximately 7000 patients are identified as high risk with a Tyrer-Cuzick score of 20% or higher. When removing the contribution of breast density and obesity, the estimated number of high-risk individuals is approximately 3000.

Assessment: Currently the Breast surgery team includes 2.0 FTE dedicated Breast Surgeons and 3 additional general surgeons. The APC position will allow for better patient outcomes by decreasing anesthesia time, ensuring high risk patients are seen regularly, and ensuring breast cancer patients are seen regularly. The position will assist with hospital-based consultations, allowing them to be seen in a more timely manner, and will see many patients with benign breast problems, which currently are not being seen by the breast surgeons due to lack of schedule availability.

Recommendation: Creation of a new FTE position within Breast Surgery. The position will be full-time M-F. The APC will have a collaborative agreement with Dr.                     .