Vital Link: Advanced Practice Providers Roles Grow in the Evolving Healthcare Chain

Legislation that would allow advanced practice providers (APPs) to supervise cardiac rehabilitation under Medicare has been bottled up in Congress for several years. But for many in the healthcare field, the larger issue is how to optimize the skills and talents of APPs across the cardiovascular service line given the changes unfolding in the delivery of patient care.

Connecting dots (& docs)

In a growing number of sites across the country, a program known as Grand-Aides USA is drawing on the experience of APPs to deliver healthcare in patients' private homes. Under the supervision of these professionals, specially trained nurse aides and community health workers are providing transitional care and chronic disease management to patients with cardiac and other disorders. A promising footnote to these home visits—intended to educate, monitor and reinforce patient adherence to medication and dietary regimens—is early data showing a 58 percent reduction in heart failure hospital readmissions (J Am Coll Cardiol 2015;65[19]:2118-36).

At Penn Medicine Chester County Hospital in West Chester, Pa., a team of physician assistants (PAs) and advanced practice registered nurses (APRNs) dedicated to cardiovascular care is able to keep close tabs on patients across the care continuum. They may see patients before a hospitalization as outpatients, during their hospital stay and play a meaningful role post-discharge by working with nurse navigators to ensure patients receive the services they need to stay healthy and prevent readmissions. Among those services is an automatic referral to cardiac rehabilitation with the appropriate diagnosis, a strategy that has pushed the hospital’s capture rate for rehab to 40 percent, compared to the national average of 20 to 25 percent, according to Janice Baker, RN, MSN, clinical nurse manager and educator.

Given the volumes of older, sicker patients and overburdened physicians responsible for increasing numbers of quality and performance measures, APPs are being seen in a bold new light. “They’re a valuable part of the heart team that helps connect a lot of the dots,” explains Baker. “They’re looking at what the patient needs not only from a medical viewpoint, but from a psychosocial-case management viewpoint. John Smith, for example, may be an excellent candidate for a [transcatheter aortic valve replacement] procedure, but how is he going to manage the postoperative concerns and does he have the support systems and referrals he needs? Doctors can’t always answer questions like those.”

There is little doubt about the clinical bona fides of APPs, a group that includes PAs, APRNs, clinical nurse specialists and pharmacists (PharmDs). “The cardiology community has embraced NPPs [non-physician providers] at least as much as any other field of medicine, in both inpatient and outpatient settings,” says Richard Josephson, MD, chair of the Cardiac Rehab Work Group for the American College of Cardiology. “Non-physician assistants are in the [operating room], and advanced practice nurses are giving anesthesia. They’re often part of team-based care for patients with advanced heart failure and for high-risk, complex interventional procedures like [transcatheter aortic valve intervention], and are involved in the evaluation and follow-up of patients with implantable electrical devices like defibrillators.”

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Extending the team’s reach

Even so, there is no shortage of healthcare experts who feel APPs with their advanced degrees and years of training are underutilized today. “People haven’t figured out how they’re going to deploy them,” emphasizes Tom Draper, MBA, president of the 3,500-member American Association of Cardiovascular and Pulmonary Rehabilitation. “Certainly, in the postdischarge transition of care, APPs offer a tremendous solution to the lack of coordination and standardization. They can help with medication adherence, with risk factor reduction and with lifestyle changes by patients.”

Draper and many others bemoan the fact that APPs have had their hands tied in the cardiac rehab space by provisions to Medicare law requiring direct, on-site physician supervision for cardiac and pulmonary rehabilitation. At press time, legislation pending in both houses of Congress would give non-physician providers the ability to meet supervisory requirements for rehab therapy, thus unyoking the process from the restricted office hours of physicians.

Since that legislation stands little chance of passage in the short run, attention has shifted to other ways to extend and enhance the role of APPs, especially in light of the widespread movement to team-based care. “It’s important that every voice on the team be heard when huddling prior to a case or reviewing it afterwards,” says Baker with Penn Medicine Chester County Hospital. “And that’s where APPs bring a really unique perspective in that they’re able to provide a bridge between the physician and the rest of the heart team.”

To that end, PAs and advanced practice nurses are playing increasingly visible roles in hospital-based heart failure, chronic angina and other cardiovascular disease programs designed to transition patients out of acute care settings. Baker suggests they could also fill a huge unmet need in skilled nursing facilities and other extended care centers, where they could adjust medications and review treatments with patients to avoid repeated—and costly—trips to the emergency department.

Wake Forest Baptist Medical Center in Winston-Salem, N.C., has carved out a unique role for PAs and nurse practitioners (NPs) as bridges between science and medicine. Trained through a PhD-PA program at Wake Forest University, these practitioners work closely with bench scientists developing new medicines to identify and enroll patients in clinical trials, then follow up by treating them, watching for adverse events and analyzing and reporting on the data. “I think we’ve just started to scratch the surface for APPs and NPs through opportunities like this,” says Zachary Hartsell, MHA, PA-C, director of PA Services at Wake Forest Baptist Medical Center. “One of the big advantages of PAs and NPs is that thanks to their broad training and patient care focus, they’re able to walk in a lot of different worlds and feel comfortable doing so.”