Maximizing NP's and PA's in Long-Term Care Practice

1. Utilizing NP’s and PA’s inLong Term Care Practice Marc G. Nevin, MD, CMD, FAAFP Long Term Care Medical Associates 4502 Starkey Road, Suite 9 Roanoke, VA 24018 540-387-9222 mnevin.ltcma@yahoo.com

2. Language Counts • “Mid-Level” Providers • “Extenders” • NPP – “Non-Physician Practitioners” or “Non- Physician Providers” ************************************ • NP/PA’s

3. The Differences Between NP’s and PA’s • Education • NP – RN ->BSN -> MSN -> FNP/GNP/ANP/APN -> DNP • PA – AA/BA/BS -> PA • Licensure • NP – combined Boards of Medicine and Nursing – independent license • PA – Board of Medicine – practicing under the license of a physician

4. NP, PA and Physician Practice Models • NP and PA work for the physician or practice • In Virginia a Physician may have protocols with 6 NP’s and 6 PA’s • NP has practice and “hires” collaborating physician • In Virginia a NP must have a collaborative agreement/protocol with a Physician • May have one or several collaborating physicians

5. Dangerous Generalization: • PA’s are well trained to interview, examine, diagnose and treat medical conditions. • NP’s are well trained to interview, examine, diagnose and treat medical conditions as they take care of patients and their families. • A Rare Combination – RN, PA

6. Working with NP’s and PA’s • What defines your practice is how you define your relationship with the NP’s and/or PA’s. • The Relationship can be Loose or Highly Structured • Styles of leadership • The Boss • NP/PA as Junior Colleague • NP/PA as Colleague

7. Protocols, Guidelines, Expectations • Protocols • Keep it Simple • Keep it Broad • Keep it Vague • What the NP/PA can do. • Training/Comfort/ Competence • Scope of Practice • What the NP/PA cannot do. • Physician sets specific limitations

8. Protocols, Guidelines, Expectations • Guidelines • This is where you can be very specific about what you want the NP/PA to do on a daily basis. The nuts and bolts of day to day practice. • Admissions, visit schedule, medical records, dictation, coding, billing, etc. • NP/PA to avoid facility issues – staffing, policies, billing, etc. • Expectations • Regulatory Compliance, Standards of Care, Practice Specific Expectations • Continuing Education

9. Compensation Models • Full-Time vs Part-Time • Full-Time • Salary & Benefits (Health, Dental, Life, Disability, & Malpractice Insurance; PTO; dues, fees, licenses; continuing education; 401K) • Salary & Benefits & Some share of profits • Salary & Benefits & Productivity Bonus • Salary & Benefits • Productivity & Benefits • Productivity & Benefits & Bonus based on success of the practice

10. Compensation Models • Productivity • Share of Revenue Produced – Share of Practice Overhead – Benefits – Employer Payroll Taxes – Employee’s Taxes – Deductions = Paycheck • Complex formula, variable paychecks • Can be pooled and calculated every 3, 6, 12 months • Simplified System • Compensation fee schedule – for each 99300 series code set a fixed $amount to be paid to the NP/PA for each code submitted. • Fee schedule determined by the Medicare/Medicaid Allowable Fees less 15% adjustment, less estimated overhead costs including all benefits (usually comes to 25-30% of expected revenue) • NP/PA can easily track their productivity and pay. Insulated from practice management issues • At risk for manipulation of visit codes.

11. Compensation Models All compensation models should account for the fact that the practice and/or the collaborating physician should be compensated from the NP/PA revenue for managing the practice, providing support, providing clinical back-up, and for assuming significant risk and responsibility.

12. Compensation Models On-Call Compensation • Bundled vs Extra Compensation • Our Model • Weekdays 5pm-8am $ 60 • Weekend Fri 5pm – Mon 8am $250 • Monday Holidays $100 • On Call Communications • Weeknight – email record of all calls to all practice staff • Weekend – “Weekend Update” – Template to record all calls by facility and emailed to all staff • All on-call emails are retained in our computers

13. Oversight and Support • Chart Review • Informal • Formal • Physician Support • NP/PA needs to know that they may work independently as they feel capable, but the Physician is always available for consultation and support with patients, families and facilities.

14. Conclusion • Physicians & NP’s & PA’s in Long Term Care Facilities • Great Patient Care • Great Facility Support • Great Practice Model • Great Financial Potential • Great Partnership

15. Questions and Answers • Q&A • Further Questions – Call, Write, or Email • DrHovland • Angel Rivera • Dr Nevin

21. LTCMA - On Call NotesDates: • LGH – 776-4000 (4021, 4022, 4023) CRMH – 981-7000 • Back-up call - Dr Nevin : cell 520-9851 home XXX-XXXX • Provider: • NURSING HOMES • *CARRINGTON PLACE at BOTETOURT 966-0056 • Fri – pm • Sat - am • Sat – pm • Sun- am • Sun- pm • *FRIENDSHIP MANOR 265-2100 • (1N 265-2135 2M 265-2078 2N 265-2136 1W 265-2142 1S 265-2137 3M 265-2139 • 4M 265-2140 2W 265-2141 MW 777-4035) • Fri – pm • Sat - am • Sat – pm