1. A Presentation of the Colorado Health Institute 303 E. 17 th Avenue, Suite 930 Denver, Colorado 80203 www.coloradohealthinstitute.org @CoHealthInst (Twitter) APNs and PAs in innovative models of care Colorado case studies April 16, 2010 Colorado Health Professions Workforce Collaborative Meeting

2. Project background and methods Follow-up to Collaborative Scopes of Care Project (2008) Panel of key informants convened to provide suggestions for appropriate clinics to interview Clinic administrators and/or providers contacted and interviewed Interview results written up Five clinics selected for this presentation as case studies 2

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4. PRIMARY CARE CLINICIANS (PCCS) 4

5. Advanced Practice Nurses (APNs), Nurse Practitioners (NPs) and Physician Assistants (PAs) APNs – Umbrella term – Registered nurses with additional training in specialty area Certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS) and nurse practitioner (NP) NPs – Type of APN usually involved in primary care although there is specialist training, e.g., family (FNP) and pediatric (PNP) – Submits claims through own license – Prescriptive authority (new rules July 1, 2010) PAs – Practices under license of a physician; delegated authority – Submits claims through supervising physicians license – Prescriptive authority 5

6. MODELS OF CARE 6

7. Team orientation of clinics utilizing PCCs Physician-run clinic with PCCs (mostly flat hierarchy) – Clinica Tepeyac – Summit Community Care PCC-run clinic with physician backup (mostly flat hierarchy) – Doctors Care – Certified Nurse Midwives at St Anthonys Central PCC independent clinic – Centennial 7

8. APNs and PAs in health care delivery models Expanding family practice models for the underserved – Clinica Tepeyac Integral partner in an extended health care network – Summit Community Care (co-located with behavioral and oral health care) Independently fulfilling a specialized need within a larger system – Certified Nurse Midwife practice at St Anthonys Central Independent general primary care; sole or one of few providers in community – Centennial Family Health Center Primary care gateway for the underserved – Doctors Care 8

9. Clinica Tepeyac: Expanded family practice Team orientation: MD as captain Staff: 20 (11 clinical); non-profit, community-based clinic Patient population – 90% uninsured, primarily Spanish-speaking PCC Roles – Independently practicing PCCs with physician as ultimate decision-maker Unique features – Almost entirely (~90%) uninsured patient population – Community-funded clinic, not an FQHC – Collaboration with oral/behavioral health challenging 9

10. Summit Community Care: Partner in extended network Team orientation: MD as captain Staff: 30 full-time, 2 part-time (~14.6 FTE clinical); non-profit Patient population: 100% low-income/uninsured/underinsured, nearly all <250% FPL PCC Roles – Mostly independent practitioners with a physician medical director, utilize established/published treatment and referral protocols Unique features – Unique location - on hospital campus – Behavioral/mental and oral health care available next door (availability of expertise) – Explicit warm referral system (which patients and providers understand) – Extensive support from county government 10

11. CNMs at St. Anthonys Central: Independent module within larger health care system Team orientation: CNM as captain with physician backup Staff: 6 clinical (4 FT CNM, 2 PT CNM), 2 support Non-profit (Centura Health System) Patient population: 20% commercial, 5% uninsured, 5% CHP+, 70% Medicaid PCC roles – Independent practitioners utilize agreed-upon protocols/guidelines to promote uniform, evidence- based standards of care and safety – Consults with physician for some treatment plans; most patients with chronic conditions referred to OB/GYN – Licensed Independent Practitioners within hospital system – can admit, discharge; fully responsible for patients Unique features: – Employed and salaried by hospital – CNMs separate and distinct clinic within hospital – Program funding from hospital foundation – Credentialed as full medical staff – Bills processed like employed physician; specific laws in CO allow direct reimbursement to CNMs – Access to billing infrastructure and credentialing structure 11

12. Centennial Family Health Center: Independent practice NP Team orientation: NP as captain Staff: NP and collaborating physician, support staff; private LLC Patient population: 30% Medicaid, 33% Medicare, 8% Workmans Comp, 20% uninsured, 9% privately insured PCC roles – Independent practitioner (bills through own license) with physician collaboration (once every 2 weeks for a half day – necessary for Rural Health Clinic status) – General primary care for community; only provider in Crowley County – Manages chronic conditions – Gatekeeper to network of specialists Unique features – Disproportionate share of older adults on Medicare (~40% of patients) – Sole provider in area – PCC-owned and operated – Only Workmans Comp clinic in the Valley 12

13. Doctors Care: Primary care gateway Team orientation: PAs as captains with physician backup Staff: 7 clinical (~6.25 FTE) with support Non-profit, community-based clinic Patient population: 50% Medicaid/CHP+, 50% low-income uninsured PCC Roles – Independent practitioners with physician support/consultation as necessary – Gatekeeper and conduit to specialist care referral network – See patients age 0-30 in clinic; qualified 30+ sent to private physician network Unique features: – PCC-run clinic with on-site physician support – Additional availability of physicians in family medicine residency next door – Insurance-like membership card usable with large network (~700) of generalists and specialists for referrals who agree to see pre-determined number of patients – Treatment protocols generally decided by PCCs (flatter hierarchy with regard to protocols) – No physicians are paid by Doctors Care to see qualified patients 13

14. APNs and PAs in continuous and comprehensive care: Medical homes 14 PCCs facilitate medical home aspect of different models of care – Track patients, navigate care system, provide access to network of specialists, even if not the explicit personal provider PCCs provide wide range of care over entire life cycle continuum – General primary, prenatal and chronic care; care management; patient education; brief behavioral health interventions (some cases); basic oral health screening (some cases) within scope of practice

15. Replication of models All clinics thought they could be replicated All clinics also thought their situation was unique Key components of a successful model – Strong leadership: champion leader – Establishing trusted relationship with providers in area – Tailoring models to fit community needs – Overcoming difficulties with reimbursement/funding sources Community support essential – Established treatment/referral protocols and trust between MDs and PCCs – Time for establishing clinic and establishing reputation – Finding the right people with compatible philosophy of care (including physicians) 15

16. Policy considerations Reimbursement parity for similar services Financial mechanisms that support rural practice, e.g. CHC funding, not available to privately owned practice Dealing with insurance companies including clarifying reimbursement policies & procedures for PCCs Establishing protocols and best practices within a clinic to promote high-functioning teams Provider education about APN and PA training/scope of practice For some models, physician recruitment is a barrier Although many of models are interdisciplinary, integrating mental and oral health is challenging Medical home – does a physician have to be the head of a medical home? 16

17. Questions and comments 17 My contact information: Erik Nesse, MA Research Associate 303.831.4200 x 212 nessee@ColoradoHealthInstitute.org