Like a quarterback reading the situation on the field and calling plays that draw on the strengths of his teammates … or a conductor who gains a deep understanding of a piece of music and how each of the musicians in her orchestra contributes a vital part of the whole … so advanced practice providers (APPs) are crucial elements of the care team.
In Penn Medicine’s hospitals, APPs like nurse practitioners (NPs) and physician assistants (PAs) serve to coordinate patients’ care and set their colleagues up for success, allowing physicians, nurses, therapists, social workers, and others to do what they do best. It’s all in the interest of restoring the patient to health. And the inclusion of APPs on the inpatient care team brings many other benefits to the hospital.
Everybody Benefits
According to Corinna Sicoutris, CRNP, director of Advanced Practice at HUP, these care providers bring something special to the care team: “the secret sauce that no one can necessarily assign a value to.” Anecdotally, she’s seen evidence that APPs really do have a positive effect on patients, if the patient panel during this year’s APP Week (celebrated across Penn Medicine) is an indication. With patients sharing how their APP caregivers helped them through becoming a living organ donor, or battling leukemia, “There wasn’t a dry eye in the virtual space. It’s always impactful and humbling to hear what their experiences are like.”
Although it varies a bit from hospital to hospital and by type of unit, for the most part, according to Sicoutris, an APP is a frontline clinician who works closely with patients and coordinates their care: “Generally speaking, it includes things like rounding on patients; managing their data; doing physical
assessments; and collaborating with attending physicians, nurses, and other members of the care team like pharmacy and respiratory therapy, etc., all in an effort to coordinate complex care for inpatients.” In a large teaching hospital like the Hospital of the University of Pennsylvania, on the medical side, patients may have either an APP or a resident overseeing their care; whereas on the surgical side, APPs would be the primary resource as they “develop a very deep expertise in the population they’re caring for.”
Whatever their area of practice, these professionals have a significant and positive effect on the institutions which employ them. That’s the main finding of a new study, published this fall by HUP’s CEO, Regina Cunningham, PhD, and Director of Advanced Practice Barbara Todd, DNP, with colleagues from Penn Nursing and several other institutions, in the journal Medical Care. Based on data from surveys, discharge information, and Medicare reports, they found that higher numbers of NPs in hospitals tended to correlate with a lower risk of mortality and readmissions, as well as lower average length of stay and average Medicare spending per patient.
In addition, the study noted that patients and nurses in hospitals with more NPs thought that care was safer and higher-quality. Nurses in these hospitals also were less likely to report feeling burned out, more likely to have high job satisfaction levels, and more likely to want to stay in their jobs. The article concluded, “Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.”
Specialty Service
Jennifer McCullough
That’s true in many instances, where APPs take on a variety of tasks, thereby allowing their colleagues to concentrate on their own areas of expertise. For example, on the Interventional Cardiovascular service at Chester County Hospital, NPs see all of the patients coming through the Cath Lab. “We give continuity of care,” says Jennifer McCullough, CRNP, Lead Cardiovascular CRNP in the program, who has been there for 14 years. “The care our team provides is comprehensive, consistent, and efficient.” Every cardiac patient at CCH is cared for by an APP at some point during their hospitalization, from preadmission to discharge.
McCullough and her colleagues see their role as being bridges between patients and other clinical care team members. “The interventional cardiologists are able to perform a high volume of cases while our team provides care discharging patients, seeing consults, and collaborating with other members of the health care team,” she explains. The APPs spend time with patients reviewing the procedure they had done, and the plan of care. They manage the discharge process, which for patients with serious heart conditions and procedures can take an hour or more. “Patients get a very detailed, thorough
understanding of their disease process, the plan of care, the importance of each medicine and of cardiac rehab, and lifestyle modifications,” she says. “We also schedule their follow-up appointment, if they don’t already have one.”
“In a more acute role, we respond to Code PCI pages, when someone is having an acute myocardial infarction,” adds McCullough. “This includes transfer from other facilities, direct arrivals in the ER, and inpatients. Often we are the first on the scene from our cardiovascular team to assess, evaluate, and
expedite transfer to the Cath Lab.”
“The value that NPs bring to the hospital include shorter length of stay, improved medicine compliance, guideline-directed care, and improved collaboration not only within our specialty, but across all disciplines,” she says. “This ultimately leads to higher hospital rankings, improved patient satisfaction, and improved overall outcomes.” She points to research they presented at the 2018 American College of Cardiology conference demonstrating improved patient outcomes from the CRNPs’ screening tool to prevent contrast-induced nephropathy (a complication in which use of a contrast agent in radiography causes kidney issues); use of the tool was associated with a shorter
length of stay, fewer adverse outcomes, and lower morbidity and mortality rates. It’s one of the ways McCullough believes her team is helping to reduce complications, prevent readmissions, and provide high-quality care.
Wearing Different Hats
Chase Schaeffer
Chase Schaeffer, PA-C, a physician assistant at Lancaster General Hospital, has also been able to collaborate with colleagues to improve care, for example by participating in quality initiatives with perioperative medicine. But he also relishes his role on the Internal Medicine team, where he cares for patients of various ages, from diverse backgrounds, with myriad conditions; for instance, an elderly woman with a broken hip, a young person admitted for substance abuse, a middle-aged man with heart issues. He sees his role as the hub of the care team, interfacing with nurses, physicians, therapists, case managers, and others: “My strength lies working within that
team context.”
Schaeffer can only think of one time in the nine years he has practiced in which a patient asked to be cared for by a physician instead. That’s a testament to the strong relationships he builds with patients, and his devotion to their wishes. For example, in the past year he cared for a patient with COVID-19 who wanted to decline intensive therapies and preferred to “pass in peace” rather than go on a ventilator. Schaeffer was there when the inevitable happened one early morning, and though he worried the family at the patient’s bedside might be angry, instead they were thankful. “In medicine, we look at victories as good medical outcomes, but sometimes the patient outcomes are something that’s unquantifiable, like a patient’s family who are reassured that their loved one’s wishes were known and respected,” he reflects on the experience, which moved him deeply.
A Path to Growth
It’s a connection familiar to many of Penn Medicine’s APPs, who have grown in number over the years. For example, when Sicoutris joined HUP 10 years ago, the hospital had roughly 90 APPs; it now employs close to 375, with almost 1,800 practicing across the Health System. “Not a lot of organizations have the executive-level support” that Penn’s APP program does, she points out.
That support continues once an NP or PA is hired. The program has invested heavily in onboarding, professional development, a solid leadership structure, and transitioning new-to-practice providers. At the other end of the spectrum, “for our most seasoned and most skilled” APPs, as Sicoutris calls them, a professional advancement pathway to Senior APPs debuted its first class last year. She points to initiatives like these as a way to enhance APPs’ engagement and decrease turnover.
As the profession continues to evolve, and more Penn Medicine patients find APPs at their bedside, their contributions to the organization will continue to grow. And that’s good for everyone, patients and providers alike, according to Cunningham. The study she and her colleagues published “demonstrated positive impact on patient and economic outcomes,” she remarks. With the “significant” number of APPs working in PM’s hospitals, “this has important implications for us.”