San Diego, CA—American healthcare is in flux, and it is not just the drugs that are changing. For many years, the traditional model of care delivery has been physicians working either solely or in the company of other physicians, but more recently, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists have assumed a greater role in patient care.
At the 2016 Annual Meeting of the American Society of Hematology, a panel of hematologists and mid-level providers shared how integrating advanced practitioners (APs) into daily practice can improve care delivery to patients with malignant and nonmalignant blood disorders.
“Incorporating APs into practice can improve patient access to care and continuity of care,” said Marc S. Zumberg, MD, Section Chief of Nonmalignant Hematology and Professor of Medicine, the University of Florida Health, Gainesville. “I also think an AP can offer a more holistic approach to care.”
“As much as it’s a benefit to patients, it’s a benefit to physicians, too,” Dr Zumberg added. “Having an AP enables physicians to see more highly complex patients and incorporate new patients into the practice while the AP handles many of the return patients.”
University of Florida Hematology/Oncology Team
As Dr Zumberg reported, the University of Florida currently employs more than 20 APs in its hematology/oncology division. The nonmalignant hematology team includes 1 PA in the inpatient setting and 1.5 advanced registered NPs in the outpatient setting.
“Our inpatient PA is the primary provider for most sickle cell patients and patients undergoing therapeutic apheresis,” said Dr Zumberg. “On routine follow-ups, the PA will round with the attending and will see new consults, especially when our fellow is getting overwhelmed. He’s also integral in training new fellows on daily activities of consult service.”
In the outpatient setting, the APs are doing the “yeomen’s work” of scheduling and seeing both return and add-on patients, he said.
“Our outpatient APs are a big liaison to our infusion center by getting patients scheduled for transfusions, and they’re also a liaison to our lab by ordering a lot of esoteric testing,” said Dr Zumberg. “In our clinic, they really perform 100% of the bone marrow biopsy.”
The University of Florida’s medical oncology group, which includes 4 PAs, is a predominantly outpatient practice. The APs are assigned to individual physicians but will work with more than 1 physician in the group.
“The [medical oncology] APs are seeing 10 to 12 patients per day, mostly in the morning, especially prechemotherapy visits,” said Dr Zumberg. “Their afternoons are spent working on lab follow-up, preparing patients for the next day, and coordinating care for chemotherapy, radiation therapy, and other procedures.” In addition, the APs cover the infusion center and perform all the bone marrow biopsies and administer intrathecal chemotherapy in the clinic.
“The malignant hematology and bone marrow transplant unit is really run by physician extenders,” said Dr Zumberg. “They round, write notes, place orders on the majority of patients, perform bone marrow biopsies and skin biopsies for graft-versus-host disease, and give intrathecal chemotherapy. They also prepare and transition patients for discharge into the outpatient clinic.”
In the outpatient setting, the malignant hematology group, manned by 5 to 8 PAs, sees 50 to 60 patients per day. As Dr Zumberg explained, PAs in the outpatient setting perform similar procedures as their inpatient counterparts.
“PAs are handling patient follow-up visits for bone marrow and leukemia. They’re coordinating care, and they’re preparing patients for transplant. They’re also integral in training our fellows to do bone marrow biopsies. With time, they’ve become increasingly autonomous and really run our unit with a single attending who’s covering as well,” Dr Zumberg concluded.
Moderator of the session, Joseph Alvarnas, MD, Director of Value Based Analytics and a hematologist/oncologist at City of Hope, Duarte, CA, commented that, in trying to deliver sustainable care, having physicians provide the entirety of care delivery is “simply inadequate.”
“In order to deliver care well and to do it in an economically sustainable way, we need really robust, value-added partnerships,” said Dr Alvarnas. “Physicians working in concert with APs offer a complementary way of treating patients that transcends a transactional mindset of care delivery. Issues that traditionally may not have been addressed as well can be addressed more effectively through these leveraged partnerships.”