VIEWPOINTS
None of our APs see patients in shared visits . In the past two years , we have focused on having our APs help during new consults for certain diseases and independently facilitate survivorship visits .
Regarding quality , my AP director and I are part of our quality steering committee , which meets frequently . Recently , our focus has been on decreasing ED utilization . We developed an outpatient rapid access clinic at the main campus to focus on decreasing utilization , particularly during normal business hours , and managing the overflow of patients who require urgent , same-day care . With this effort , we are growing our resources and trying to avoid hospitalizing patients . It is being led entirely by the APs .
Non-billable productivity is another issue we have been addressing . All four of us have had conversations about this topic and how to capture the productivity of an AP and the support they provide an oncology practice from a billing standpoint .
Dr . Kurtin : Whom do you interact with in achieving these outcomes ?
Dr . Astrin : Within The Network , from the corporate perspective , our value-based care team takes the lead on practice transformation – type initiatives . Each independent practice then has a quality program lead and a physician champion . These teams are in frequent contact , with multiple calls throughout the month . In my role , I participate on those task forces and committees to make sure that new programs are being discussed , including how they will look in practice .
I offer my expertise around areas that would impact the APs in those practices , which often allows us to expand their roles and be more visible in that quality process . We also have data platforms updated daily that give us live quality scores for individual providers and practices , as well as provide insight on any potential areas for improvement . We share that information among our practices to create benchmarks across our network .
As Mailey mentioned , how we value APs from a fiscal perspective is a passion project of mine . I have worked with everyone from the clinical leadership of our practices to the president of our network and our CFO on ways to demonstrate our APs ’ value , which is different than how we value physicians . I ’ ve also created a framework used within our practices that incentivize APs to achieve certain quality scores . We allow practices to pick the metrics most relevant and valuable to them .
Ms . Zecha : It ’ s incredibly important for APs and AP leaders to know the key players who are driving their organization . I have a longstanding relationship with our quality team , and that relationship is very important .
Our medical director has been extraordinarily supportive of our APs . Our current high-priority initiative involves improving the coordination of care . Part of that is , obviously , to meet the needs of our patients , but we also want to make sure that patients receive the care they want and need , as opposed to what the provider thinks they should receive . It requires a group effort among our teams , of course , but our palliative care NP has been vital to rolling out that work . Often , APs are the providers who know patients best , so they should be the ones having those conversations and they are embedded in all these groups .
We established what we call the “ undiagnosed masses clinic .” In an academic setting , doctors typically do not want to see a patient who does not have a pathologic diagnosis , so we set up a completely independent , APrun clinic that sees patients who are referred from our general medicine clinics . The AP initiates the workup , and then assigns them into the right disease group if a cancer diagnosis is confirmed .
Our acute care evaluation , or ACE , clinic is another big initiative aimed at keeping patients out of the ED , which is similar to the clinic that Mailey described . For example , the ACE clinic takes patients who may have a neutropenic fever and , instead of sending them to the ER , APs treat them in the clinic if appropriate . The implementation of this clinic has substantially reduced our ED visits . Also , although it is a completely AP-run clinic , we incorporate the multidisciplinary team when needed , including our nursing professionals , pharmacy staff , and medical directors , to make it run smoothly and consistently .
Dr . Kurtin : Mailey , you mentioned working with your AP directors and other colleagues . Are there key alliances or connections within your institution or system that are critical to achieving these outcomes ?
Dr . Wilks : Yes , we do work very closely with our leadership – physician chairs , department chairs , nursing directors , and anyone who might be involved in the quality or fiscal projects . In the example of our rapid access clinic , we ’ ve been working closely with leadership across our different teams to find solutions to take care of patients , especially when the physicians ’ schedules are full . That was one of the reasons that we consider the quality , fiscal , and regulatory aspects of having our APs practice more independently and help with consults for undiagnosed cancers , or anemia , or lymphadenopathy , or monoclonal gammopathy .
We ’ ve become more creative within our project management team to find other ways that our APs can practice independently , as well as collaboratively , to support our patients . As one example , we launched a new initiative to allow our APs to prescribe chemotherapy , which is not allowed within our institute , but is allowed in our state . Our quality director , pharmacy team , nursing team , and physician chairs are working together to develop a policy allowing our APs to independently prescribe chemotherapy so we can treat patients quickly and safely .
Of course , we also have several standing meetings with our executive AP leaders across the Cleveland Clinic enterprise , and with our quality director to review all ongoing projects .
Dr . Kurtin : These are all areas where people may not understand the full integration of APs in practice and their roles in achieving overall programmatic outcomes and goals . In the next discussion , we will talk more about how AP efforts to effect change impact the patient experience and how APs stay informed about new accreditation , quality , and fiscal policies . ●
Literature Scan : Advanced Practice Edition
To say that this has been the most difficult 20 months for health-care professionals in our lifetime is an understatement . Just when we thought there was a light at the end of the COVID-19 tunnel , enter the Delta variant , vaccine hesitancy , and vaccine and COVID-19 misinformation . Resilience and burnout are in a fine balance among health-care professionals , and resilience and quality of life are at the core of patients ’ cancer journeys . Here , I ’ ve highlighted three recent publications from advanced practitioner ( AP ) authors that focus on factors important to resilience , communication , and patient-reported outcomes and quality of life .
— Sandy Kurtin , PhD , ANP-C , AOCN , Associate Editor , ASH Clinical News
Klein CJ , Weinzimmer LG , Dalstrom M , et al . Investigating practice-level and individual factors of advanced practice registered nurses and physician assistants and their relationship to resilience [ published online ahead of print , 2021 Jul 29 ]. J Am Assoc Nurse Pract . doi : 10.1097 / JXX . 0000000000000639 . Researchers used an online survey to investigate factors associated with resilience among 1,138 APs actively engaged in a clinical role , representing a diverse cross-section of practice settings . Factors positively associated with resilience included older age , autonomy , a collegial relationship with collaborating physicians , working full time , and availability of collaborating physicians . Except for age , these factors are amenable to institutional and professional intervention . Intentional onboarding and mentorship programs , role delineation to support APs practicing to the full scope of their licenses , and programs to cultivate a workplace culture of community , accessibility , and collaboration will likely create a more resilient and satisfied AP workforce . This study was conducted in 2017 , before the COVID-19 pandemic .
Mohanraj L , Sargent L , Elswick RK , Jr ., et al . Factors affecting quality of life in patients receiving autologous hematopoietic stem cell transplantation [ published online ahead of print , 2021 Jul 24 ]. Cancer Nurs . doi : 10.1097 / NCC . 0000000000000990 . In this longitudinal study , adults with hematologic malignancies undergoing autologous hematopoietic cell transplant ( AHCT ) were asked to complete validated questionnaires to measure frailty , fatigue , quality of life , and cognition before and after transplant . Fatigue and quality of life improved post-AHCT in this sample ( mean age = 58.9 years ). Although frailty worsened after AHCT , most patients were found to have frailty before AHCT . The authors found that patients reporting fatigue were more likely to report inferior quality of life , perceived well-being , and functional well-being after transplant . Surprisingly , increased fatigue correlated with improved cognition . Systematic frailty assessment and programs to improve pre- and post-AHCT functional and emotional status are critical to improving patientreported outcomes .
Stephens JM , Thorne S . When cancer is the self : an interpretive description of the experience of identity by hematology cancer patients [ published online ahead of print , 2021 Aug 4 ]. Cancer Nurs . doi : 10.1097 / NCC . 0000000000000984 . Reseachers conducted face-to-face interviews with 14 adults with hematologic malignancies to describe how their identity is affected by their diagnoses . Three major themes emerged : the unique cancer-self , the invasion of cancer opposed to self , and the personification of the cancer within self . Interestingly , few of the patients ever used the term “ cancer ” when describing their experience , rather named their individual disease . Finding support groups of patients with the same disease proved to be difficult for patients , most of whom had a type of acute or chronic leukemia . Eliciting the patient perspective and continuing to capture patient-reported outcomes using validated tools will improve our ability as clinicians to develop programs and processes to meet the needs of patients living with hematologic malignancies .
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