Advanced Practice Providers

1. Advanced Practice Providers PracticeMatch Annual Conference Loews Coronado Bay Resort Tuesday, March 4, 2014 Laura Screeney, FASPR Corporate Director, Office of Physician Recruitment North Shore-LIJ lscreeney@nshs.edu (516) 823-8874 www.nslijphysiciancareers.com ,

2. Today’s Session • Physician Assistants • History • Training • Scope of Practice • Become an expert in your state(s) • Nurse Practitioners • History • Training • Scope of Practice • Become an expert in your state(s)

3. Physician Assistant "More than a nurse, less than a doctor“ Look Magazine -1966

4. Physician Assistant • A physician assistant (PA) is a medical professional who works as part of a team with a doctor. • A PA is a graduate of an accredited PA educational program who is nationally certified and state-licensed to practice medicine with the supervision of a physician. • PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. • All 50 states and the District of Columbia allow PAs to practice and prescribe medications. • The PA educational program is modeled on the medical school curriculum, a combination of classroom and clinical instruction. The average length of a PA education program is 27 months. • PA education includes instruction in core sciences: anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory science, behavioral science and medical ethics. • PAs also complete more than 2,000 hours of clinical rotations, with an emphasis on primary care in ambulatory clinics, physician offices and acute or long-term care facilities. Rotations include family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine and psychiatry. • In order to maintain national certification, a PA must complete 100 hours of continuing medical education every two years. • There are currently 170 accredited PA programs in the United States. The vast majority award master’s degrees. • PAs can continue into post graduate programs in clinical specialties such as: surgery, OB, neurology, critical care/trauma.

5. PAs: The Beginnings-1960’s • 1961-Charles Hudson, MD in the Journal of the American Medical Association, calls for a “mid-level provider “from the ranks of former military corpsmen. • The World Health Organization (WHO) begins introducing and promoting new categories of health care workers in developing countries (e.g., Me'decin Africain, Dresser, Assistant Medical Officer, and Rural Health Technician).  • 1964-Eugene A Stead, Jr., MD, disillusioned by organized nursing’s rejection of the advanced nurse clinician program that he and nurse educator, Thelma Ingles had developed, announces in a letter to Duke Hospital Administrator, Charles H. Frenzel, his intention to develop a program for the “physician’s assistant”,” using former military corpsmen, modeled after the relationship between Amos N. Johnson, MD, and Henry Lee “Buddy” Treadwell, his assistant, that was well known in the North Carolina community. • 1965-the nation’s first “physician assistant” educational program is inaugurated at Duke University. The Program accepts four former Navy medical corpsman. • Dr. Stead based the curriculum of the PA program on his knowledge of the fast-track training of doctors during World War II.

6. PAs: The Beginnings • 1966-The military services combined their various physician assistant programs to form the Interservice Physician Assistant Program (IPAP), located at the Army Medical Department Center and school (AMEDDC&S), Fort Sam Houston, Texas, due to mandatory cutbacks by the federal government. • 1967-The first PA class graduated from the Duke University PA program on October 6th. • 1968-Hu C. Myers, MD, establishes the first baccalaureate degree program for PAs at Alderson-Broaddus College in Philippi, WV.

7. PAs: The Beginnings • 1969-Richard Smith, MD, launches the MEDEX program at the University of Washington, Seattle WA in partnership with the Washington State Medical Association, to rapidly deploy ex-military corpsmen to rural primary care practices throughout the Northwest. • The American Hospital Association and the Joint Commission on Accreditation of Hospitals release a report on the "Utilization of Physician's Assistants in the Hospital." • At the request of the Assistant Secretary of Health, Roger O. Egeberg, Alfred M. Sadler, Jr., MD and Blair L. Sadler, JD of the National Institutes of Health (NIH) complete an intensive nationwide survey of all licensed allied health occupations. Their report recommends that State Medical Practice Acts be amended to permit the practice of physician assistants under the supervision of a physician as long as both the PA and MD are responsible for these activities. • 1970-Kaiser Permanente becomes the first HMO to employ PAs.

8. PAs-1980’s • 1981-NCCPA introduces the Physician Assistant National Recertification Examination (PANRE) PAs who fail the exam are recertified for two years, but are required to retake the examination.  • 1983-NCCPA's Physician Assistant National Certifying Examination (PANCE) is redesigned to include three components: a general knowledge core, an extended core in either surgery or primary care, and a “checklist” clinical skills component (CSPs). • 1987-National PA Day, October 6th, is established, coinciding with the 20th anniversary of the first graduating class of PAs from the Duke University PA Program, and, coincidentally, the birthday of Eugene A. Stead, Jr., MD.

9. PAs-Recognition of Specialty Training • The National Commission on Certification of Physician Assistants (NCCPA) develops Certificate of Added Qualifications (CAQ) programs that allow PAs to earn formal recognition of their specialty expertise - in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopedic surgery and psychiatry. The first CAQ examination is held nationally on September 12, 2011.

10. PAs today • 2012-The physician assistant master’s degree, for the third consecutive year, is rated by both Forbes and Money magazines as the most desirable advanced degree in terms of employment opportunity, income potential, and job satisfaction. • NCCPA reaches a major milestone and certifies its 100,000th PA since its inception in 1975.

11. PA Scope of Practice • History and physical examination • Order and interpret laboratory tests • Develop and initiate treatment plans • Patient education • Write prescriptions • Perform minor outpatient surgery • First assist at surgery • Research and administration

12. The Employment Agreement • A PA must have a supervising physician. • The supervising physician does not have to be on site, nor present during exams. • Number of PAs that a physician can supervise varies by state. • Supervision can be available remotely-telephone is okay (key in remote locations, or even across town). • Supervising physician is responsible for conducting regular chart reviews. • PA can perform services in line with scope of supervising physicians practice.

13. PA-Fellowship Training Programs • Acute Care-1 • Cardiothoracic Surgery – 2 • Critical Care/Trauma-5 • Dermatology - 1 • Emergency Medicine – 10 • Hematology/Oncology-1 • Hospitalist - 1 • Neonatology – 2 • Neurosurgery - 1 • OB/GYN - 2 • Oncology - 1 • Orthopedic Surgery -2 • Otolaryngology-1 • PA/NP-1 • Psychiatry-1 • Surgery - 5 • Urology – 2 • Vascular Surgery-1

14. APPAP Training Programs

15. State Laws • All States Have Laws in Place Regulating PAs. • All States Have Laws Authorizing PA Prescribing. • Require PAs to be Certified in Order to Receive a License. • Requirements vary by State; become an expert in your state(s).

16. Over 86,500 PA’s Nationwide

17. Nurse Practitioners All NPs must complete a master's or doctoral degree program, and have advanced clinical training beyond their initial professional registered nurse preparation. Didactic and clinical courses prepare nurses with specialized knowledge and clinical competency to practice in primary care, acute care and long-term health care settings.

18. Nurse Practitioners • There are approximately 167,000 nurse practitioners (NPs) practicing in the U.S. • An estimated 11,000 new NPs completed their academic programs in 2010-2011. • 93% of NPs have graduate degrees. • 97% of NPs maintain national certification. • 18% of NPs practice in rural or frontier settings. • 88% of NPs are prepared in primary care; 68% of NPs practice in at least one primary care site. • 87% of NPs see patients covered by Medicare and 84% by Medicaid. • 43% of NPs hold hospital privileges; 15% have long term care privileges. • 96.5% of NPs prescribe medications, averaging 20 prescriptions per day. • NPs hold prescriptive privilege in all 50 states, with controlled substances in 48. • 60% of NPs see three to four patients per hour; 7% see over five patients per hour. • Malpractice rates remain low; only 2% have been named as primary defendant in a malpractice case. • Average NP is female (96%) and 48 years old; she has been in practice for 12.8 years as a family NP (49%).

19. Distribution, Mean Years of Practice, Mean Age by Population Focus Population Percent of NPs Years of Practice Age • Acute Care 5.6 7.0 45 • Adult+ 19.3 10.9 50 • Family+ 48.3 9.5 48 • Gerontological 3.2 11.6 52 • Neonatal 2.0 12.3 47 • Oncology 1.0 8.3 47 • Pediatrics 8.5 13.3 49 • Psych/MH 3.0 8.5 52 • Women's Health 9.0 14.7 49

20. Nurse Practitioners-1960’s • 1965-Dr. Loretta Ford and Dr. Henry Silver develop the first Nurse Practitioner (NP) program at the University of Colorado. • 1967-Boston College initiates one of the earliest master's programs for NPs.  • 1968-Directed by a nurse and physician team, the Boston-based Bunker Hill/Massachusetts General Nurse Practitioner Program begins.

21. Nurse Practitioners 1970’s • 1971-One of the first family NP programs, PRIMEX, opens its doors at the University of Washington. • 1973-More than 65 NP programs exist in the U.S. • National Association of Pediatric Nurse Practitioners (NAPNAP) is established. • 1974-The American Nurses Association (ANA) develops the Council of Primary Care Nurse Practitioners, helping legitimize the role. • The Burlington Randomized Trial Study finds that NPs make appropriate referrals when medical intervention is necessary. • 1975-The University of Colorado offers its first continuing education symposium for NPs . • 1978-The Association of Faculties and Pediatric Nurse Practitioners (AFPNP) is established and begins developing PNP curriculum. 

22. Nurse Practitioners 1980’s • 1980-More than 200 NP programs or tracks are available to students and 15,000-20,000 NPs are Guidelines for Family Nurse Practitioner Curricular Planning is published after five years of development at the University of New Mexico. • 1984-A steering committee forms to study the need for an organization representing an estimated 24,000 NPs nationwide . • 1985-The American Academy of Nurse Practitioners (AANP) is established. • AANP has 100 members at end of first year. • 1987-$100 million has been spent by the federal government on NP education. • 1989-Ninety percent of NP programs are either master's degree granting programs or post-master's degree programs. • Publication of the Journal of the AANP begins. • The first official AANP National Conference is held in Philadelphia with 158 attendees.

23. Nurse Practitioners 1990’s • 1992-AANP actively works with nursing associations such as the Royal College of Nursing UK to develop role of NPs internationally. • Barbara J. Safriet writes in the Yale Journal on Regulation supporting the NP role • 1993-AANP forms Certification Program as separately incorporated entity . • 1994-Mundinger publishes "Advanced Practice Nursing – Good Medicine for Physicians" in The New England Journal of Medicine, further supporting facts that NPs are cost-effective and quality primary health care providers . • 1999-Estimated 60,000 NPs in the U.S.

24. Nurse Practitioners 2000’s • 2000 -AANP initiates the Fellows program. • 2001 -September 11 – AANP enlists support of hundreds of NPs to offer aid in NYC and D.C. • Estimated 87,000 NPs in the U.S. • 2003 -Estimated 97,000 NPs in the U.S. • 2004-National Nurse Practitioner Week, held annually in November, is recognized in a proclamation by U.S. Congress. • The American Association of Colleges of Nursing (AACN) publishes position paper on Doctorate of Nursing Practice. • 2005 -Estimated 106,000 NPs in the U.S. • 2009- Estimated 125,000 NPs in the U.S.

25. Nurse Practitioners 2010 • AANP health policy activities center predominantly on Health Care Reform, CMS regulations, Medicare payment, Appropriations, Medical Home and state and local issues of importance to NPs and their patients • AANP participates at a meeting with White House Office of Health Reform to review the primary care perspective on preventive care, access, coordinated primary care, quality of care, payment and the need to recognize all primary care providers as solutions to the health care crisis • AANP attends President Obama's White House briefing on Health Care Reform legislation • AANP celebrates 25th anniversary • AANP Fellows (FAANP) celebrates 10th anniversary • AANP has 28,000 individual members and 151 groups (as of May 2010) • Estimated 135,000 NPs in the U.S.

26. AANP • On January 1, 2013, the American Academy of Nurse Practitioners (founded in 1985) and the American College of Nurse Practitioners (founded in 1995) came together to form the American Association of Nurse Practitioners (AANP), the largest, full-service national professional membership organization for NPs of all specialties. 

27. Nurse Practitioners • NPs are licensed in all states and the District of Columbia, and practice under the rules and regulations of the state in which they are licensed. • They provide high-quality care in rural, urban and suburban communities, in many types of settings including clinics, hospitals, emergency rooms, urgent care sites, private physician or NP practices, nursing homes, schools, colleges, and public health departments.

28. NP Scope of Practice • Advanced physical assessment • Order and interpret laboratory tests • Develop and initiate treatment plans • Patient education • Write prescriptions (APNP) • Case management/referral

29. NP Practice Demographics • 80% in urban/suburban settings • 20% in Rural/Frontier settings • Physician practice sites 44% • Community health 14% • Long term care 7% • Hospitals 4% • Home health & all other 31%

30. Nurse Practitioner Programs • Acute Care = 70 • Family Practice = 281 • Geriatric = 84 • Neonatal = 48 • Occupational Health = 21 • Oncology = 13 • Pediatric = 103 • Perinatal = 2 • Primary Care = 26 • Psychiatric/Mental Health = 76 • Rural - Adult = 2 • School Health = 8 • Women's Health = 59

31. DNP Programs

33. NP National Certification • American Nurses Credentialing Center (ANCC) (Acute Care, Adult, Adult-Gerontology Acute and Primary Care, Adult Psychiatric – Mental Health, Diabetes Management, Advanced Emergency, Family, Gerontology, Pediatric, School) • Pediatric Nursing Certification Board (Pediatric Primary & Acute Care, Pediatric Primary Care Mental Health Specialist) • American Academy of Nurse Practitioners (AANP) (Adult -Geriatric & Family Medicine) • National Certification Corporation (NCC)(Neonatal and Women's Health)

36. Building your candidate pool…

37. Sourcing • American Academy of Physician Assistants • PA Specialty Associations • American Academy of Nurse Practitioners • ANA Nurse Career Center • Physician Specialty Associations • Health E Careers • School Program & Alumni Postings • State Associations • Health System, Clinic or Hospital Web Site • Social Media