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Understanding Scope of Practice: Page 2 of 2

Understanding Scope of Practice: Page 2 of 2

Roland Goertz, president-elect of the American Association of Family Physicians and chief executive of the Family Health Center in Waco, Texas, says his practice uses the teamwork model for all midlevels they employ. Under his approach, each PA or NP is paired with a physician, a nursing assistant, and an office staff person to create a team. “It’s not about one person; it’s about the group of people taking care of a patient,” he says. “We want people who want to be part of the team concept and understand their role in providing care.”

Though PAs and NPs differ slightly in their scope of practice, Goertz says his office recruits both for midlevel positions, focusing on individual strengths and weakness rather than title. All require training to bring them up to speed with the policies and procedures of the practice. “We acknowledge that there are differences between NPs and PAs, but there are a lot of differences in their training, too,” he says, referring to the fact that some have gone through a formal classroom education and others utilize distance-learning courses. “So we try to level that out during the interview process. We try to find out what they know and what they still need to learn, and we look for people who understand their role in providing care and want to be part of the team.”

Dean Health Systems also integrates midlevels, both PAs and NPs, using the patient-centered medical home approach, in which each member of the team performs at the highest level of her training. Bain’s office divides the staff into “pod teams,” which consist of one physician, one midlevel provider, two “roamers” (or medical assistants) and one practice nurse. As the model evolves, however, Bain believes the pods will eventually include a one-to-two ratio, with one physician and two midlevels, plus the ancillary team members. “In the old days, we had a supervising physician for every midlevel, but now we have all the physicians in our group sign a practice agreement for coverage or supervision of all our midlevels,” he says, noting the process helps improves continuity of care.

The goal at his clinic, of course, is for all patients to see their own physician, says Bain. When that doctor is unavailable, the patient is then directed to the midlevel provider within that pod. The third choice is another physician in that pod and the fourth choice is a PA or physician in another pod. “We have a target patient panel of 1,900 patients per doctor, but we found that when you add a PA or NP to the team you add half that again — making it a total of 2,700 patients per pod,” says Bain.

Educate your patients

However, Bain stresses that hiring midlevel providers and utilizing them effectively are two different things. Practices need not only provide for adequate supervision, but also take steps to educate patients on how their PAs or NPs can benefit them. “Some patients still say, ‘Nope, I just want to see the doctor.’ But most patients are becoming more open to the team concept, and they like the midlevels because many times they have faster access to them,” says Bain, noting neither the NP nor PA is better than the other. “My next available appointment might be four weeks away, whereas an NP might be available to see them today.”

Dean Health System typically leaves their midlevel’s schedules open so that half the time they’re available for acute care cases and the other half they’re dedicated to follow-up appointments. To help promote the team concept of patient care, Bain says, the clinic includes a picture of the whole healthcare team in every exam room. “Our business cards also include the name of the patient’s primary doctor on the front, along with the names of everyone on that team, because patients need to understand that it doesn’t make any sense for them to call the doctor for medication refills when a medical assistant might be able to provide that,” he says. “We mobilize different members of the team for different tasks.”

As the healthcare industry evolves and patients become older and sicker, Bain says he believes midlevel practitioners will become increasingly more critical to lowering costs and improving care. “Patients are getting older, sicker, and their problems are more complicated,” says Bain, noting patients also demand more of their caregivers these days than they once did. “The physician of old would often dictate the course of treatment for the patient and the patient would say, ‘Whatever you think doc.’ Very few asked any questions. That type of paternalistic approach would not fly at all today.”

By using midlevels to educate patients, provide routine care, and assist with coding and documentation, physicians will be better positioned to bring their expertise to bear, focusing on chronic disease management and more complex diagnoses. And that, says Bain, is good for patients. “Medicine has changed over time and we need to be creative in our approach to delivering care,” he says. “It’s kind of folly to think that patients’ entire healthcare needs can be compressed into a standard 15-minute office visit, or physical exam, once a year.”

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 12 years. Her work has appeared on CNNMoney.com, Bankrate.com, and Healthy Family magazine. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the April 2010 issue of Physicians Practice.

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