The Exec: Advanced Practice Providers Key to Managing Physician Shortages

Including advanced practice providers in a practice redesign benefits physicians and patients, nurse leader says.

If the question is how to take care of more—and sicker—patients with fewer physicians, one answer lies in redesigning a practice with advanced practice providers (APPs) and allowing each clinical team member to practice at the top of their scope, says Allison Dimsdale, DNP, NP-C, AACC, FAANP, associate vice president for advanced practice for the Private Diagnostic Clinic at Duke University Health System.

Dimsdale has led Duke’s ambulatory practice redesign and watched while the strategy spread into all of the health system’s ambulatory specialty practices.

Dimsdale spoke with HealthLeaders about how she and her colleagues collaborated to benefit both Duke’s clinicians and patients.

This transcript has been lightly edited for clarity and brevity.

HealthLeaders: What is your definition of practice redesign?

Allison Dimsdale: With healthcare, we're experiencing what we have come to define as a new normal. We have a lot of patients, and we don’t have the resources that we used to have. The data is clear, and to me, it's shocking. The Association of American Medical Colleges talks about a shortfall of 139,000 physicians by the year 2033. We’re going to have to find a way to take care of people.

My focus is advanced practice providers, which are nurse practitioners (NPs), and physician assistants (PAs). We have 335,000 NPs and 159,000 PAs in practice in our country, and many more coming out of school. It makes sense that if our absolute top goal is to take care of lives, then we have to optimize our clinical workforce. We need to not burn out our physicians; we need to bring new clinicians into the mix. And then we have to manage all of the cultural pieces that are involved in putting them together in the same practice. And that's what I call practice redesign.

Forty years ago, you would have a single physician and maybe a nurse, and they would do everything for a patient. Now, a patient might have a primary care provider, a cardiologist, a nephrologist, a physical therapist and then they might want to see a nutritionist, so they already have a team. If we can put those teams together in such a way that they have more resources rather than having to struggle to find the resources, then, ultimately, their health is going to be better.

So, we navigate these market trends and we look at all these new regulatory updates, which are coming down the pike all the time, and then we look at new and innovative workforce strategies to figure out what our new normal is going to be. When I think about redesigning our practice, it's redesigning from that single physician—or in an academic medical center, a bunch of physicians—and finding a way to put all of these different team members together, with everyone working to the top of their scope, their licensure, and their training. Then they are bringing care in a multidisciplinary manner to that patient, and I believe those patients are going to be healthier in the long run.

Allison Dimsdale, associate vice president for advanced practice, Private Diagnostic Clinic, Duke University Health System / Photo courtesy of Duke Health

HL: When is it necessary to re-engineer the way patients receive care?

Dimsdale: I think about it in two ways. Number one is in the complexity of that patient who’s getting out of the hospital, sooner than perhaps they would have 10 or 15 years ago. They need a higher level of care from the ambulatory standpoint, and when I say ambulatory, I mean they go to an office, or maybe they have homecare services rather than lying in bed at the hospital.

When there are not enough providers or clinicians and the patients are sick enough that they need people with more expertise, then we have to rethink this. In our medical center, we looked around and said, “Here at Duke, we have 1,400 nurse practitioners and physician assistants, many of whom have a 10- or a 20-year tenure. They’re working with world-class physicians. How about we deploy them to see patients autonomously, but still collaboratively as a team member with the physicians and take care of these patients?”

And so, when we started doing that specialty, we found that the patients loved it. They had more resources. They had more choice of visits. If somebody was in the hospital and they needed to have a follow-up visit three or four days later, they weren’t being asked to wait. There was always someone to see them.

The other part of this is, as we try to optimize our clinical workforce, we focus on quality care. We’ve got 40 years of workforce data and outcomes data, which show that the patients who are taken care of by APPs have just as good an outcome as the ones who are taken care of by physicians. We know their care is safe, and we also know that it's cost-effective; we can know that because a physician is paid two to three times more than an APP and an APP is going to bill a little bit less. Same quality, same safety, and yet it's cheaper care, so it’s a win-win for the patients and it’s a win-win for the healthcare organization, whether it's a little private practice at the end of a country road or a large academic medical center. It just makes sense.

A lot of physician groups will get upset and say, “Well, you know that an APP is not a physician,” and I will never say that they are. They don’t have that level of training, but the data shows they can do 85% of what a physician can do. The other 15% should be done by a physician and by elevating the complexity of what the physician does in the course of their daily work by offloading a lot of that other 85% to the APP, then we have everybody working to the top of their scope and we still increase access.

HL: You’ve touched on this a little, but what does practice redesign look like in your organization?

Dimsdale: We started in 2010 in my practice of cardiology, and along with the cardiologists, we had a group of six NPs and PAs that had about 75 years of combined experience with high-quality training and yet, they were working far below scope, basically doing the work of a nurse. We had an access issue because our next available appointment for a new patient was a month away, and that's not OK if somebody's calling because they're dizzy or because they have chest pain.

We received funding to hire nurse clinicians to form the hub of an interprofessional team consisting of four physicians, one APP, and the nurse clinician. The model that we chose for our patient population was that the APP would see return patients, acutely triaged patients, and hospital follow-up patients. This freed up the physicians to see complex patients new to our practice and establish a plan of care. This met our aim of all members of the team working to the top of their scope of practice, while increasing access for our patients.

From there, it was so successful that it spread across our health system in all our ambulatory specialty practices. Each one looks a little bit different because each specialty practice is going to be different. For example, in dermatology, APPs might do general dermatology and the physicians might do the surgical subspecialty part of that.

As we move toward value-based care, we have to take care of lots of people, especially as Medicaid is expanded throughout our country. My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent. It’s worked. We have amazing people who come to work with our organization, and they stay.

HL: What are key tips you would suggest in implementing practice redesign?

Dimsdale: I would say first of all, look at where the need is. Then look at the resources that you may already have that are well-trained, that are well-ensconced within your organization, that understand how you practice. And then figure out if you can change anything about the way that they're working right now, in order to get them to the top of their scope.

Ask them, “What are you doing that you think could be done by someone else to the top of their scope?” This is a question that's being asked all over the country right now about advanced practice, but it’s also true for physicians, nurses, and medical assistants, as the nursing shortage is real. We need to be creative about how we deploy people, and how we put them together in teams. Some of our teams use EMTs while others use athletic trainers alongside physical therapists. We’ve found that utilizing pharmacy technicians to help with some of the paperwork required by pharmaceutical companies and insurance companies can be incredibly beneficial.

Once you've figured out who you have, and how you can use them to achieve your goal, then anticipate where the barriers are going to lie, and have a ready answer for every naysayer who comes toward you with a complaint or reason why it can't work—because it's working all over the country and it's working beautifully.