Physician Shortage 4/20/2015. Utilizing Advanced Clinical Practitioners Under the Affordable Care Act Dennis A. Taylor, MBA, DNP, ACNP-BC, NEA-BC

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1 Utilizing Advanced Clinical Practitioners Under the Affordable Care Act Dennis A. Taylor, MBA, DNP, ACNP-BC, NEA-BC Physician Shortage The AAMC estimates a physician shortage of 63,000 by 2015 & > 100,000 by 2025 Primary Care Physician Shortage 1

2 The Landscape National and local trends are driving the need to assess innovative approaches to Advanced Clinical Practitioner (ACP) utilization What is an Advanced Clinical Practitioner? Advanced Practice Registered Nurse (APRN) Nurse Practitioner (NP) Certified Nurse Midwife (CNM) Clinical Nurse Specialist (CNS) Certified Registered Nurse Anesthetist (CRNA) Physician Assistant (PA-C) The Carolinas HealthCare System 45 acute care facilities 900 care locations over three states (NC, SC, GA) Over 1 million primary care patients served / 4.7 million visits $8.5 billion in revenue Over 2,500 providers (Physicians and ACPs) in the CHS Medical Group 2

3 Regional Overview CHSMG Managed CHSMG Affiliated Network The CHS Recruitment Education/Onboarding Retention/Satisfaction ACP Recruitment Barriers Hard to Fill Positions Very specialized positions where there are very few ACPs trained Positions in regional/rural areas are hard to fill Lack of Recruitment Incentives Sign on bonuses, better relocation reimbursement, etc. Job Codes Job codes are not organized to allow proper use Compensation Compensation review does not currently include national benchmarks 3

4 The Need for Advanced Clinical Practitioners Objective CHS ACPs in acute care settings are often hired from non-acute settings Clinical Outcomes ACPs receive on-the-job training with their supervising physicians ACPs often find themselves ill prepared for many clinical situations CHSlacks strong reputation as a best place to work for ACPs Fragmented communication with ACPs across the System Satisfaction Provider dissatisfaction with ACP/MD clinical partnerships Underutilization leads to ACP disengagement (not practicing at top of license) Physician frustration with increasing work load and patient demands High MD/ACP ratio = Highercostprovider workforce Costs Vacant ACP positions yield lost revenue, decreased patient satisfaction & decreased accessto care Length of time to recruit skilled providers contributing to increased costs.to create value for patients. Initiative Development Over Time Monthly Town Hall meetings Meetings with key stakeholders Postgrad Fellowship New ACNP Program Center for ACP Executive Committee, Steering Committee & 3 Workgroups Components of Business Plan Executive Summary Project Overview Situation Assessment Management and Operations Alternatives and Recommendations Financial Projections Management Action Plan 4

5 Leadership Approval & Funding CHS Management Company Business Plan ROI Executive Vice President Sponsorship Planning and Investment Team (PIT) Board approval Mission Advanced Statement Practice Carolinas HealthCare System Center for To innovate on the care delivery model by defining and optimizing the role of Advanced Clinical Practitioners across the Carolinas Healthcare System Center Vision for Advanced Statement Practice Carolinas HealthCare System To be chosen by Advanced Clinical Practitioners as the best place to work and deliver cost effective, superior patient care 5

6 ME CAP Functional Units Carolinas HealthCare System Center for Advanced Practice (CAP) Department A CHS investment in the future. CAP Core Services 5 FTE A centralized coordinating center to optimize core services related to Advanced Clinical Practice. CHS Fellowship Program 56 Fellows 4 FTE A one year post-graduate transition to practice ACP fellowship program designed to develop foundational specialty-specific skills and knowledge. Acute Care NP Program 36 Students 1.5 FTE A partnership to offer a local advanced degree program to educate acute care nurse practitioners who will possess the skills needed by CHS as well as familiarity with CHS s culture, values and expectations. Functions of the Center for Advanced Practice Collaboration & Coordination with Physician Leadership Coordination of ACP Education within CHS (undergraduate, post-grad and CME) Resource for Departments and Practices on issues surrounding ACP employment (Regulatory/Credentialing) Center for Research on Best Practices of ACP Utilization (Practice Model Innovation) Center for Professional Development & Mentoring Platform for System-wide Communication Address ACP Satisfaction/Retention 6

7 ACP Fellowship Program Specialties Acute Care 15 Fellows every 6 months / 30 annual Urology (1) MICU / Pulmonary Critical Care (3) Trauma / Surgical Critical Care (2) Sanger Heart and Vascular Institute Cardiology (2) Carolinas Hospitalist Group (6) Emergency Medicine (1) Urgent Care 3 Fellows every 6 months / 6 annual Adult Urgent Care (2) Pediatric Urgent Care (1) Primary Care - 10 Fellows every 6 months / 20 annual Family Medicine (2) Internal Medicine (2) Pediatrics (2) Behavioral Health (2) Palliative Care (2) Fellowship Program Process New employee goes to work with all orientation, credentialing and hospital privileging done and prepared for productive workon Day 1 20 ACP Fellowship Program One-year post-graduate fellowship program provides exposure to an array of complex disease processes in the acute, primary, and urgent care settings in order to prepare ACPs with the skills necessary to be successful in delivering superior patient care while in a protected learning environment 6 acute care, 5 primary care, and 2 urgent care specialties Fellow retention post Fellowship = 90% 7

8 There is a Pipeline of New Graduates Established PA Programs in NC Duke University, Durham East Carolina University, Greenville Wake Forest University (including satellite campus Appalachian State University) Methodist College, Fayetteville New local Physician Assistant programs Wingate University Northeastern University Elon University Lenoir Rhyne University High Point University Gardner Webb University Nurse Practitioner Programs Acute Care NP (Adult to Gerontology Nurse Practitioner with an Acute Care Focus) Duke University, Durham, NC University of South Carolina, Columbia, SC UNCC/CHS There is a Pipeline of New Graduates Established PA Programs in NC Duke University East Carolina University Wake Forest / Baptist Health Methodist College, Fayetteville New local Physician Assistant programs Wingate University Elon University High Point University Gardner Webb University Northeastern University Lenoir Rhyne University Acute Care Nurse Practitioner Programs Duke University University of South Carolina UNCC/CHS Acute Care Nurse Practitioner Program: a partnership with UNC Charlotte Developed in response to the need for well-prepared advanced practice nurses to meet the acute care needs of our patient population August 2013 program launched with 12 students August 2014 second cohort of 18 students starts program August 2015 third cohort of 12 students / post-master s certificate avail. Applications increased by 93% from 2013 to 2014, which reflects increased need for acute care ACPs in the CHS workforce as well as increased awareness of the program 8

9 Value Created Improved clinical outcomes with ACPs obtaining the clinical knowledge and expertise needed to practice at top of license, Increased physician & patient satisfaction Higher ACP satisfaction = leads to increased retention; decreased vacancies Lower turnover cost, including recruitment, training/orientation, lost productivity, new hire costs Lower recruitment costs = due to fewer vacancies; enhanced pipeline shortens recruitment cycle Lower provider workforce cost= sufficient quality and quantity of providers allows CHS to shift the ACP to MD ratio Building a Team The CAP will prepare our System and our physicians for their role as team partners with ACPs to foster team-based patient-centered care. Ensuring Success Moving Forward The CAP will help to o Address the impending physician shortage o Improveclinical outcomes through innovative training and education o Increase MD and ACP satisfaction o Innovateon skill optimization strategies that affect costs o Transform the CHS patient experience 9

10 Integration of ACPs to transform the primary care delivery model Primary care curriculum that focuses on patientcentered, team-based care models Integrated System of Care Education of ACP Fellows in virtual care technology techniques Deployment of ACP workforce to serve rural and underserved populations Develop and publish evidence-based ACP-specific treatment practices ACP Compensation Redesign with HR & CHSMG Transformative Operations Educate ACP workforce on LEAN practices and performance improvement Enhanced recruitment pipeline (lifecycle of ACP) Streamlined and improved onboarding, orientation, and review of DOPs Integration of ACPs onto HEN and QSOC committees Interprofessional Education (IPE) Rotations with 10 inpatient departments Quality & Patient Experience Enhancing skills through casebased scenarios utilizing simulation and team learning discussions Education of ACP workforce on quality metrics that impact patient care Integration of pastoral counseling, ethics, and interdisciplinary topics 10

11 Delivering a highly trained ACP workforce to be rapidly infused into acute, urgent, and primary care settings to meet growing demand Strategic Growth Local publicity and national recognition promote the CHS brand ACP Fellowship program popularity is bringing higher quality ACPs to the System Opportunity: Skill Optimization Physicians have not been educated about how to work with and best collaborate with ACPs Will require culture change among the physician community Need for more experimental practices that focus on ACP utilization and delivery of care in various settings Top of skill-set practice Access/convenience/work-life balance Cost savings often dependent on physician compensation model 11

12 Opportunity: ACP Leadership According to a recent report by The Advisory Board Company titled Realizing Full Value of the Care Team, progressive systems include ACPs in medical group leadership Lack of ACP representation can lead to disengagement The organization misses out on key insights from these clinicians ACPs should be included in discussions affecting providers ACPs should hold both committee positions and executive roles ACP Leadership at CHS Service line ACP leaders aligned with CHS Medical Group Chief ACP for CHS and CHS Medical Group CAP positions CHS to be preeminent in defining the role of ACPs in a value-driven care delivery system. CAP Advisory Board Katie Kaney, Ph.D, Co-Chair Beth O Connell, ANP, Co-Chair Scott Lindblom, MD Michael Ruhlen, MD Geoff Rose, MD Robert Alexander, MD Thomas Batchelor, MD Alisahah Cole, MD Joseph Stegman, MD Patricia White, MD Lindsey Kuhn, PA Mary Ann Wilcox, RN Michael Gibbs, MD Ginger Marshall, ACNP Mary Hall, MD Dennis Taylor, DNP, ACNP The Center for Advanced Practice positions CHS to be preeminent in defining the role of ACPs in a valuedriven care delivery system. 12

13 Questions 13