Hi, everyone. My name is Caitlin Brady. I'm a nurse practitioner here at Children's National in Washington, D.C. in the Physical Medicine and Rehabilitation Department. Today, it's my pleasure to present all about my role as the advanced practice provider within the physical medicine and rehab field. We're going to talk about what the best use of the role is, what is the role exactly, and then after my presentation, you're going to hear from two of our physiatrist colleagues about what their experience is with the advanced practice provider's role. To start off, none of the presenters in this presentation or on the panel have financial disclosures in pertinence to this presentation. Our learning objectives are the following. First, we're going to talk about what is the educational background of advanced practice providers and what is their scope of practice. You're going to see that not one size fits all and that the scope of practice does vary from state to state. Another objective is for the learner to be able to describe the best use of the role within our field of physical medicine. Then, recognizing the application of the advanced practice provider within different rehabilitation practices. Again, our panel at the end of this presentation is going to accomplish that. While we're only hearing from two of our physiatrists, obviously, everyone has a different experience and I'm just hoping that this can open up a conversation really throughout the country about what the advanced practice provider does within the PMR field. A little bit about me. I'm a pediatric nurse practitioner. I received my bachelor's of science in nursing from the University of Scranton in Pennsylvania and my master's of science from Catholic University here in D.C. I'm certified as a pediatric nurse practitioner in primary care. Prior to my nurse practitioner role, I was a registered nurse in an acute rehabilitation hospital for five years. I have both adult and pediatric experience. I've been here in my current role for three years. I do a little bit of inpatient and a little bit of outpatient. I have both the acute hospital setting experience, the acute rehab experience, and also outpatient experience. I also have a certificate from Harvard Medical School from their pediatric leadership program. Why this presentation and why now? Really, what inspired me to get this group together to put this talk together is what I saw at the AAPMR conference last year in 2019. It was my first time going, but I was really surprised that I didn't see any other nurse practitioner or physician assistant there. Now, that doesn't mean that they weren't there, but the overwhelming majority of attendees were obviously physiatrists and trainees. For me, that really lit a fire within me to look at the role within the field and really think about how we could promote further participation from the advanced practice provider population. As I know, there are many of us throughout the country practicing within the field of PM&R. Obviously, COVID-19 is increasing the demand on us as frontline providers. Any risk for burnout or overwork that existed before COVID-19, I feel, is underscored by the pandemic. I think that, as I'll talk about a little later on in the presentation, that advanced practice providers really have a shot in helping share this burden and workload. We just have to find the right way to do it. As always, rehab medicine is a growing field. Advanced practice providers can just contribute that much more to further growth within the field. I feel very fortunate to work at an institution and with a chief who shares that vision, I would say. I'm hoping, again, that this presentation could open up a discussion, not only around the country, but within the academy about advanced practice providers and their role in the field. First, let's talk about the overview of the role. This might seem a little basic, but what I will say is each certificate for a nurse practitioner, each area of practice is a little bit different. It's actually not as straightforward as you may think. I'm going to cover nurse practitioners first and physician assistants after, but just so everyone is on the same page as they listen to this presentation, the term advanced practice provider encompasses both roles, both NPs and PAs. Let's start talking about the overview of the NP role. Really, what are we? What do we do? Most of you know this, but we're clinicians that blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management. All of us do this, but I think the nursing model of teaching teaches nurses in general to really focus in on holistic care and disease prevention. A nurse practitioner sort of furthers that expertise as they practice, and they carry that emphasis on disease prevention and health management with them from that undergraduate registered nurse kind of framework of education into that master's degree. All NPs must complete a master's or doctoral degree program and have advanced clinical training beyond their initial professional RN prep. You can have either a master's or a doctorate degree, which is typically a DNP, a doctorate of nursing practice, and be a nurse practitioner. To be clear, just because you have the master's or the doctoral degree, that doesn't automatically make you a nurse practitioner. You then have to go on to be certified in your respective specialty. Just to talk a little bit about the history of the nurse practitioner role, I put some highlights on the next couple of slides just so everyone can understand when this role really started to evolve. In the United States, that really started in the 1960s. The first nurse practitioner program was developed at the University of Colorado in 1965. That really kicked things off in terms of education and starting to really define this role as something separate from the registered nurse. In 1968, as you can see, the Boston-based Bunker Hill slash Massachusetts General Hospital nurse practitioner program begins. That's still a very, very strong program today. It's very unique because it's hospital-based, whereas most NP programs currently are university-based. The MGH program, like I said, is really interesting. It's a really cool model. Actually, it can be done in a way that you go from, I believe it's five years, you go from RN to master's and then on to doctorate if you so choose. Again, that's a different model because it's hospital-based. In the 1970s, the American Nurses Association starts to recognize primary care nurse practitioners as a legitimate role. Several, several studies have been done. The Burlington study is just a very famous and well-known study within the world of nurse practitioners that took place in the 70s. In 1983, there were between 22,000 and 24,000 nurse practitioners in the US. We're going to see how that number changes. Again, that was in the 80s. In 1989, 90% of NP programs are either master's or post-master's degree programs. Our NP journal starts publication. The first official NP conference takes place in Philadelphia with 158 attendees. Again, the numbers change over time. This is where we're starting. In 1992, the AANP works with nursing associations such as the Royal College of Nursing in the UK to develop the role of NPs internationally. Just a word about that. The role of the NP internationally is really interesting. After studying in London and talking with some colleagues in Canada, it's pretty clear to me that the NP role, I would say it waxes and it wanes. Sometimes, everyone's on board and embracing the role. It's an existing well-defined role within these countries. Other times, I feel like they've stepped away from it. At least, that's what health officials I've spoken to in those countries have shared with me. I was recently in London last year. It sounds like they're ramping up to embrace that NP role again. It's gone through a lot of definition and then redefinition over the years. In 2010, we start to really see the NPs take hold of the policy world. The AANP starts a health policy activity center, all about CMS regulations, Medicare payment, health care reform, medical homes, and start talking about what are the important issues to NPs locally and their patients. In 2012, just to review, in the 1980s, there were between 22,000 and 24,000 NPs. In 2012, there are approximately 157,000 NPs in the US. Then, in 2019, which is obviously the most recent number, the AANP surpasses 100,000 members and there are more than 270,000 NPs in the United States. Really, the role grew in a very short amount of time and it grew significantly. This is where we're going to see the NP role vary from state to state across the country. That's within legislation. Laws and regulation vary state by state in the US for nurse practitioner practice. What they do is they use a colored system of green, yellow, and red, which classifies the autonomy of practice for nurse practitioners. Advocacy efforts within states often just examine the color of the state in the US and lobby for change if it's appropriate. Obviously, red is the most restrictive practice. Yellow is middle of the way and green is full autonomy. A green state, they're not going to advocate for any change, but obviously, the red and yellow states, a large portion of their advocacy efforts are probably going to be dedicated to autonomous practice. We're going to talk about what these colors mean. What does a green state mean? As I said, that's pretty much a fully autonomous practice for NPs. NPs can evaluate, diagnose, order and interpret diagnostic tests, initiate and manage treatments, basically prescribe whatever medication, including controlled substances, under the state board of nursing. The NP license still remains with that state board of nursing. In green states, you don't need to have a physician signing off on anything that the nurse practitioner does. However, what does exist is what we call collaborative practice agreement. That essentially says that NPs and MDs work side by side as peers in that state. Yellow states. Again, this is our middle of the road state. The yellow states reduce the ability of NPs to engage in at least one element of NP practice autonomously. Most of the time in yellow states, that's going to be with controlled substances and prescribing. Typically, in a yellow state, what you would have to do is have an MD sign off on a medication. MD sign off on that prescription of a controlled substance. Red states. Laws in this color state restrict the ability of NPs to engage in at least one element of NP practice, but it's often more than that. Often in red states, you have to have an MD sign off on all documentation done by an NP, prescriptions, orders, all of that. This is a map. This is going to show us all of the states throughout the country and what color they are in pertinence to autonomy of NP practice. I just want to point out, I am obviously in Washington, D.C., so I have a lot of knowledge about my surrounding area. Virginia is really interesting because Virginia actually was green, I want to say maybe like five years ago, and then it turned yellow and then it went red. There, to my knowledge, the only state that has taken this back step from what they did, and I'm not quite sure of the circumstances surrounding that, but they are a red state, but they were once green. I just find that to be incredibly interesting. You can see throughout the country where things vary. I would say you see a lot of out in the Midwest, you see a lot of green. I think that's probably because availability of provider and patient access. That would only make sense. I could talk about this map for a really long time because I just find it so interesting. When I was in nurse practitioner school, I actually got to attend a meeting being in Washington, D.C., talking about legislative laws pertaining to nurse practitioners. It was really one of the most fascinating things I had ever heard because they invited physicians to that meeting to discuss their viewpoint and what color they felt each state should be. Very interesting stuff. The education of the nurse practitioner. What do we do? What does our education include in taking this next step from bedside nurse to frontline clinician? Here's an educational pathway I've created just to give you a visual of what that education looks like. Everyone has to be a registered nurse who's a nurse practitioner. You do get your undergraduate degree in nursing, bachelor's of science in nursing. You really need at least two years of nursing experience. Not all schools are going to require that, but I always tell people when I'm talking to candidates who want to go to nurse practitioner school, you really need to have two years of nursing experience at the bedside because that is just going to make you a strong clinician. I would caution someone against going to a school that said they can jump right in right out of nursing school when they get their undergraduate degree because I am just such a firm believer you need those bedside skills. Then after you get two years of nursing experience, you move on to your master's program, which can take anywhere from two to three years depending on if you go part or full-time, and then you become certified. After that, you take your boards and you become certified. There's this new thing popping up all over the country and they are fellowship programs for new nurse practitioners students. This really takes place in the acute care setting. I know Boston Children's has a fellowship program in several of their departments. I believe Children's DC, we have one or two within our various specialty departments here, but this is a newer thing which I think is great. When I trained to work in my current job, I really stuck with the chief of the division for two years when I started here before I was fully independent and on my own. Then of course, you move on to career NP and you could move on to get your PhD or your doctor of nursing practice. Like I said earlier, it's really important that everyone understands just because you have a master's of nursing, that does not make you a nurse practitioner. You do have to sit for a board exam and become certified. There are four specialties. There's neonatal, pediatric, family, and geriatric nurse practitioner. Some people are certified in all four. That's a lot of schooling, but most people, maybe one or two certifications. Then within each specialty like pediatrics, you can do acute or primary family. I believe you can do acute or primary. Neonatal doesn't have that obviously. The neonatal specialty is really for NICU nurse practitioners. It's a very special track. Just to worry about the family versus the pediatric certification. Obviously, I'm pediatric certified, so I'm a bit biased here. Often, you'll see family nurse practitioners practicing in pediatrics. I think that's okay, but it's important to understand that they have the ability to care for patients across the entire lifespan. Technically, newborn to geriatric, but their training within pediatrics is actually very limited. They only have a semester of pediatrics in school. Whereas the pediatric nurse practitioner, you are pretty much doing pediatric courses throughout those three years. There's a large, large focus on development and understanding of the ages and the stages within the pediatric nurse practitioner curriculum. The physician assistant. PAs are integral members of the health care team in many hospitals and primary care offices. The role of the physician assistant is really to practice medicine under the direction and supervision of a licensed physician. Training in the path to getting your PA certification is very different than that of a nurse practitioner. A PA is never really going to be autonomous from a legal standpoint. You can never have a PA who is seeing patients without the oversight of a physician. They do assist with the diagnostic process, the development and management of treatment plans. They can prescribe medication, and they serve as often as someone's primary health care provider. Again, they are usually, from a legal standpoint, checking in with a medical doctor or physician. With thousands of hours of medical training, PAs are versatile and collaborative. This is very true. They practice in every state and every medical setting and specialty. Really, they can practice anywhere. I think most of us know the role and responsibilities of the PA. The one thing that they do that nurse practitioners cannot is assist in surgery. That's really not a good use of the NP role because that's just not part of the training. With the PA, they can assist in surgeries. A lot of the time in neurosurgery settings, you'll see the PAs assisting. Again, similar slide to the educational pathway for nurse practitioners, this is the educational pathway for physicians assistants. They receive their undergraduate degree, which can really be in anything, but I think a lot of PA schools obviously like to see some type of science background within the undergraduate experience. After they graduate from college, getting their undergraduate degree, they then are required to practice in a clinical setting as either a nurse's aide or medical assistant. each school has a different requirement as to how many hours. So, you know, I was talking to a friend recently who is a PA and she was telling me that it can vary, you know, from 200 to 600 hours, it really is going to depend on the school. And then they go to PA school for two to three years, depending on, again, the program. And then they can sit to be certified and then they have you have your career PA. Again, legal considerations for an NP versus a PA, a physician must staff and co-sign all PA notes. Billing is always under the physician when working with a PA. Okay, so now to talk a little bit about nurse practitioners in the field of rehab medicine. So as of the 2019 AAPMR conference, there are less than 30 nurse practitioners registered within the academy. There are likely at least twofold of that number practicing NPs within the field of rehab medicine. I do not believe for a second that there is under 30 nurse practitioners or PAs practicing within the field of rehab medicine throughout the country. So, you know, it's not a well known specialty within the field of nursing and PA schools. I frequently go and talk to students at Catholic University here in DC. And every year I go and give my rehab presentation. And every year, a couple of people say after this is a really cool field, I had no idea that existed. So I really, personally have taken it upon myself to make it my mission to sort of get the word out there about rehab in general, let alone talking about nursing and nurse practitioners within this field. But, you know, really, I think any student I would say that comes in and rotates here with us in our department, really has such a positive experience and honestly, I've had at least you know, six or seven now and all of them have been very, very excited about the field and very plugged in while they're here. Many of them have expressed it have expressed interest working in this field after their rotation. So I really think it's it's a good mission to not only get advanced practice providers plugged into the academy, but then to further talk about like, how can we spread the word to get more engagement? All I think all certifications minus the neonatal certification are able to practice and appropriate to practice within rehab. You know, pediatric family and geriatric, we see all those populations across the rehab spectrum. So why not? So what is my personal role within rehabilitation medicine? So I mentioned I did a hybrid of inpatient and outpatient. So about a year ago, we created the nurse practitioner role to be able to practice on the inpatient rehab unit here in DC and it's a collaboration with the National Rehabilitation Hospital. That has been a really interesting process. I think that it has taken a lot of education of the staff, sort of some of the administration at the hospital, as well as you know, education even within our own department here about what exactly that role is going to accomplish. And we've done a lot of learning. But we do have so that's part of my job is to be the nurse practitioner on our inpatient rehab unit. We also do a lot of consults where I work. So nurse practitioners here we see the consults and we will discuss with our physicians here in our department. But each of us sort of has our own specialty. One of my NP colleagues does has a lot of NICU experience. So she basically sees the NICU patients multiple times a week. And we'll just sort of check in and do that pretty autonomously, I would say. So consults wise, you know, it's nice because we could see a lot and we don't necessarily staff every single consult. We also have a subacute facility that I go to and see consults weekly by myself autonomously. So that's nice as well. And then outpatient mode. So we have several multidisciplinary clinics here at Children's National and the neuromuscular multidisciplinary clinic and brachial plexus multidisciplinary clinic is sort of my covered clinics. So I go and practice independently within those clinics. One of my other colleagues is a nurse practitioner and she does our spina bifida clinic. So again, kind of having those specialty like niche areas within the field of rehab is something that the nurse practitioner can do and gain enough experience to be able to practice fairly independently within those multidisciplinary areas. We do a lot of Botox follow ups independently, we will see an occasional new patient here or there. But we will typically either discuss or staff it with one of our physiatrists here. Just to obviously sort of go over especially if it's someone who doesn't have a diagnosis, you know, all of those new cases that I'm sure everyone is familiar with listening to this. So right before we move into the question and answer panel with our physiatrist, I just want to say I really love my role here. I think the nurse practitioner role within the field of rehab medicine is one that is really important and actually really useful when it's done the right way. Of course, I'm a little biased, but I think that's why the panel will be useful is you're going to be able to hear the perspective of two physiatrists who not only work with nurse practitioners, but also hire them into the practice. So, you know, I think that there's definitely a space and an area for this within physical medicine rehab. And I really, really hope this presentation, like I said, is the start of many conversations about the advanced practice provider role within physical medicine. And please feel free to reach out with any questions you may have for me. So we're now going to jump into our question and answer panel with our two physiatrists, Dr. Susan Affman, Chief of Rehab Medicine at Children's Hospital Colorado and Dr. Justin Burton, the Chief of Rehabilitation Medicine here at Children's National. The format of this will be I will ask a question and each physiatrist will then give their respective answers before moving on to the next question. So, Dr. Burton, I'll start with you. Our first question is, how do you incorporate advanced practice providers into your respective practice? Well, we have at Children's National, we're fortunate we have three advanced practice providers. And so we have the advanced practice providers in a various in a variety of settings. So, you know, looking at the clinical angle, we have one of our advanced practice providers, who's a clinical nurse specialist, is staffing one of our outpatient specialty clinics, working with kids with complex care. And in that setting, that clinical nurse specialist is supervised one on one by an attending physician. In our other two nurse, nurse practitioners or APPs, but both of them happen to be nurse practitioners. One of them does primarily all outpatient practice, she does see people patients independently, both as part of a multidisciplinary clinic, and then separately in an equipment clinic. And she was had some supervision in the beginning, but it is now practicing independently. And our other nurse practitioner does a variety of roles, and we know her well. And she has a background in teaching on this subject. But that nurse practitioner functions in a role where she's working on an inpatient unit, in consultation fashion, as well as an outpatient practice. And that's just on the clinical side. And then when we extend it to the academic, the research side, our advanced practice providers take part in all of our academic series as well. So they both participate in our didactic sessions with our residents and fellows in the other programs outside of our physical medicine rehab division participate in those sessions and also give some of the lectures and host some of the didactic sessions. And then from a researcher scholarly perspective, all three of our nurse practitioners, or APPs, I should say, are participating in that fashion in the fields in those areas where they have their clinical specialty. So we have one nurse practitioner who does a lot of work with the spinal muscular atrophy and the muscular dystrophy community. One of our nurse practitioners does a lot of research with spina bifida, and in advocacy work locally here in the DC area. And our third, our clinical nurse specialist does research in looking at hypertonia and hypertonia management. So a very, you know, all three of these APPs have a variety of experience, both clinical and then again, academically and research wise as well. Dr. Afghan? Sure, I'm happy to talk about the different roles. I'm going to speak about it in from two perspectives. I've been in two healthcare systems. So I'm having a little bit of a blend of both of those healthcare systems. But currently, I work with two advanced practice providers, both are nurse practitioners, and they have different roles. So one of the APPs is acting as a program coordinator of our neuromuscular program. And that's really a combination of clinical coordination, so helping coordinate some of the clinic schedules, screening new evaluations and determining the urgency of that care, and the appropriate clinical venue. And then the person, this APP is also providing clinical care in the different neuromuscular clinics that we run. The strength of this model has really been that the nurse practitioner can develop a really strong relationship with the child in the family and provide a lot of continuity of care. This nurse practitioner is the primary point person for all families who have children with neuromuscular conditions. So the in between care that's required, whether it's acute medical questions, or again, needing help with coordination of care or writing letters and medical necessity, this nurse practitioner is really instrumental in providing that support. The second role that I have seen used and currently are using is a nurse practitioner who has a very strong clinical care focus on a specific patient population. So whether it's mild traumatic brain injury or concussions, spina bifida, or the care of children with cerebral palsy, the nurse practitioner is really focused on a particular population so that he or she has the ability to really dive deep into that population and really understands the needs of the children with that particular diagnosis. So in the setting of APP that's caring for children with cerebral palsy, that's providing clinical care in our cerebral palsy clinic or our general rehab clinic, doing relatively straightforward injections, a bunch of line of toxin, generally in the upper lower extremities. And that's done in the clinic setting. And again, the APP in the context of a specialty clinic is also able to provide some of that in between clinical care and helping to write letters of medical necessity and peer to peer reviews and things like that. The third role that I've had an APP incorporated in is on the consult service on the in patient side of our hospital. And that is working in tandem with the attending physician or in combination with the team of an attending physician and a fellow or resident evaluating new patients who have consultative needs, and then doing some of the longer term follow up. So this role and I can talk a little bit when we talk about some of the challenges, this has been a little bit more of a challenging role, but I do believe can be really satisfying for the APP and allowing that APP to provide really great care to the children on a consult service. Awesome, thank you so much. Our next question is when recruiting an advanced practice provider, what background and experience are you looking for? And Dr. Burton, we can start with you again. Well, like Dr. Afghan, being in pediatric rehabilitation, you know, really looking for that background in that field, you know, it can be difficult to find that combination of pediatric rehabilitation, but I will look for those separately. So do they have does that APP have experience in training and pediatrics, they have experience in training and adult physical medicine and rehabilitation. And then, ideally, we have candidates with experience in both of those fields. And, you know, so I don't, when recruiting an APP, I don't know, pretend to know all the various degrees, and I have, you know, a pretty good understanding of that. But I'm looking for that, you know, just looking at the taking a candidate. You know, there's through the nurse practitioner role, for example, there's the certified pediatric nurse practitioner role, there's a certified family nurse practitioner role, and I'm going to look stronger, stronger at a candidate with that certified pediatric nurse practitioner training and, and that, you know, that in terms of their academic and their certification. And then on the flip side, if you're looking more at the clinical side of things, you know, if I'm looking at to bring someone on to our team, in terms of nursing experience, if I'm looking again, going back to the nurse practitioner role, be looking more at somebody with a certified rehabilitation registered nursing background, as opposed to a different nursing background, again, just looking for that, that clinical experience in that area. And looking to get, you know, when I get a friend to get more specific, if I have an individual role, I'm looking at, you know, as Dr. Avkan has mentioned, you know, we have, you know, different APPs in different clinical settings, I'm going to look for experience in that setting. So if I'm looking for somebody, an APP who can help support the inpatient rehabilitation team, or even being seeing some of those patients, and working with the attending physician, I would love to have a candidate who's got background in bedside nursing, for example, in a pediatric rehabilitation medicine unit, or as conversely, if I'm looking for somebody with that out for that, on the outpatient side of things, you know, it would be great to have a, an APP who has some background in working, for example, in a clinical setting, like in an outpatient clinic, or is serving as an outpatient clinic nurse. So I really try to look at that, that background, both in terms of their certification, as well as their clinical experience. And I've been very fortunate that the last two people that we have hired at Children's National have had that direct experience, that outpatient APP has that had that direct outpatient experience as a clinic nurse, and our inpatient APP had direct experience as a bedside nurse on a pediatric rehabilitation unit. Dr. Avkan? Well, I couldn't agree with Dr. Burton more. And he has been very lucky, it sounds like in being able to recruit and hire nurse practitioners who bring a lot of experience. So as Caitlin, as you reviewed your CV, you talked about your background, I thought, wow, this would have been awesome to bring someone on who really had that experience. And it's challenging there, you know, you, you know, we have a small field. There are not a lot of inpatient pediatric rehab units. And so to find someone who brings the experience that you brought is, you know, is, is hard. So as I'm looking for someone, I'm really looking for someone who's bright, who's engaged, and has a very strong clinical background. I think inpatient nursing is a challenge. And so someone coming with inpatient nursing experience, whether it's floor nursing, or ICU nursing, tells me that that person has the ability to do a lot of multitasking, has strong assessment skills, and I would expect really strong interpersonal skills. So that's a real bonus. I've also had the opportunity to recruit a nurse practitioner who came from an emergency department setting. And while there's not a lot of continuity of care in emergency department setting, again, the ability to quickly assess a patient and, and move that patient along multitasking because that that person has multiple patients that they're caring for. I found that that also brings a lot of great experience to the to the rehab setting. I want someone who has a really clear understanding of the patients that we serve. So again, I said that it's hard to find someone who has pediatric rehabilitation experience, and that's okay. As long as the person who are going to be hiring understands the complexity of the patients that we serve, the chronicity of the conditions that that child and family may have, and also the amount of case management that we as rehab providers do. And that's not the glamorous, the sexy side of our field. Writing a letter of medical necessity or doing a peer to peer is not always fun, but that's an incredibly important part of our of our specialty. And so I want to make sure that the person who's going to be taking this position really understands that that's expected of them. I also mentioned that one of the APPs that I get to call a colleague is a program manager of a large neuromuscular program. And so having someone who has skills in program development, experience managing a sometimes rowdy team of providers, having leadership skills, and also program development skills is going to be really important to the success of this person in that role. Great. Our next question is, what challenges have you experienced when incorporating an advanced practice provider into your practice? And Dr. Apcom, we're going to start with you. You touched on this a little bit already. Sure. You know, I think that it takes time to onboard any provider, whether it's a physician provider, or an APP. Now, when I onboard a physician provider, I'm onboarding someone who's done a pediatric rehab fellowship or did a combined residency in Pediatrics and Rehabilitation. So they have a lot of time and experience under their belt. Bringing on an APP with no experience, which is something that I've done now a couple of times, takes a lot of time and very intentional programming to assure that that person's gonna be successful. Now, I'm not always gonna be that person who's gonna be mentoring the new APP, so making sure that the attending physician, the rehab physician who's going to be supporting this APP is well aware of the amount of time and effort it takes to do that. And I think not taking that time up front, really successfully onboarding that person is a missed opportunity. I did mention that I found it challenging, or as a practice, we found it challenging to bring on a provider onto our consult service. And it was someone who's very bright and was very engaged in the work, but had little rehab experience. And so what that meant was, and also had little inpatient experience. So what that meant was we were having to teach this provider not only the evaluation, the medical evaluation of a patient on a surgical service or an intensive care service or general medical service, but we also then had to teach this provider about rehab medicine. We had to talk about the rehab history that we take, the functional assessment that we do, and the physical exam, and then the interventions that we offer, whether it be bracing or equipment or therapy services. And I think we as a group found it challenging to really have to train on all aspects of not only the consult side of things, the medical side, but also the rehab side. So it's not impossible by any means, but it was challenging because of how much we had to teach this provider who came with really little experience. Yeah. Dr. Murphy? Yeah, absolutely. I would echo what Dr. Apkon said about the supervision piece. And it's variable. Again, we were very fortunate at Children's National to have people with that direct experience having worked with us, for example, as a bedside nurse or a nurse in clinic, including writing those letters of medical necessity, and participating, the bedside nurse participating in team conference and hearing how we approach things and hearing how we manage patients and working with us to manage those patients. So I'd echo that that level of supervision obviously depends on the education and the experience, the background of that APP that's being onboarded. And as Dr. Apkon mentioned, it is vital that that supervision and that working with that person in the beginning, you know, obviously lays the framework or the groundwork for the rest of that person's, you know, how they're gonna practice within your group, within your hospital and your system. I'd say something else specifically that I didn't anticipate running into one of the challenges we ran into was just working with the resident and fellow physicians. So as many of us as pediatric rehabilitation programs, we have different, we actually have two residency programs that work with us, and then we have our Pediatric Rehabilitation Medicine Fellowship. And two of our APPs are, well, all three of them have their specialty areas, but two of them help run multidisciplinary clinics and they can function independently within the District of Columbia here. And so, you know, we set up, we've had to be a little creative with how we set up our schedules for our residents and fellows, because one of the requirements for their training program is that they're supervised by an attending physician. So although I would argue that some of our APPs have more knowledge and more experience with some of these conditions, R2, for example, or spina bifida, and our other one being muscular dystrophy, that we try to set up those clinics so those residents and fellows have the opportunity to work one-on-one with those attending physicians. That's been one of the challenges with incorporating APPs. And I know it's maybe a little specific for our program, but I think that other programs have run into that as well. Lynn, can I add one more challenge that I found, and it was really wearing my administrator's hat. When the physician and APP are working side-by-side during sort of the training portion of the onboarding, part of what I would do, or we would do as a practice, is have that nurse practitioner do some of the documentation, because that's also a skill that you need to learn. Once the nurse practitioner does that documentation, then they are required, at least in the states that I've been in, to bill for those services, which means the physician wasn't billing. So as I was helping to train a nurse practitioner, our volumes of patients didn't change over the first couple of months, but my revenue, specifically the charges that I was dropping was dramatically decreasing. And so it affected my bottom line. Now, I guess I share that with you to say, as someone's considering bringing on a nurse practitioner or a PA, you want to think proactively about that piece and work with the hospital or the system you're in to make sure that the physicians aren't necessarily getting penalized if they're not billing. And again, every practice in the financial models are completely different, and it may be a weak point for some, but for me, it definitely was eye-opening. It wasn't something I expected and something I had to really navigate and negotiate with the hospital as we were recognizing it was happening. Thank you for that. Our next question is going to be, how do you provide support to the advanced practice providers in your respective practices? Dr. Apkon, we can start with you again. Well, let me start by talking about the onboarding process because I think that that really is fundamental to the support that we provide. And again, I mentioned having a strong onboarding process is really going to be key to the success of this provider being an independent practitioner. I've had the experience of onboarding multiple nurse practitioners, none of whom came with rehab experience. And so I really had to kind of have a reset of my expectations and recognize that this provider, while bringing a lot of great experience, was in many ways like a medical student. And so my expectations of knowledge and the starting point was going to be as a medical student progressing to a resident and ultimately progressing to a fellow. Initially in the clinic setting, the support that I provided was one-on-one time with the nurse practitioner or the APP and the patient. So first it was a shadowing experience quickly followed by the two of us going in together and having the nurse practitioner or the APP obtaining the history or maybe I would do the history and they would do the physical exam or they would do the entire visit and I would sit quietly and maybe add some questions or add some physical exam components or talk about the interventions that we're going to do in many ways like I do with our residents and fellows. And then several months in after having that part of the training, the nurse practitioner and I would have parallel clinics. So I would have a panel of patients and he or she would have a panel of patients. And I would always be available as that provider would step out of the room to have them present to me, come up with a plan. Sometimes I would go in and again, like I would do with a resident or fellow, do some brief assessments or sometimes I would just have that APP go back in and continue on with their plans. And then finally, and currently, we typically have a nurse practitioner in a team room with a physician. So if there's any questions, one came up yesterday, a patient that was new to our practice and the nurse practitioner had some questions and she was able to pull in a physician to help assist with the final assessment and the planning. So that's some of the support on the clinical side. We have, again, with the onboarding, we have the nurse practitioner, the PA come to our residents or fellow training programs and we provide CME as well, just as we would a physician. And the one other point actually, as we're talking about the clinical support, it's support around the documentation. So for many APPs, if this is their first job, they've not written a note before and certainly haven't written the pediatric rehab note in my case. And so sitting down one-on-one and reviewing, the documentation, whether it's a clinic note or a letter of medical necessity, but really reviewing it and giving feedback and making sure that you're providing that additional support. I'll just jump in jumping in there. I agree with Dr. Eichmann on the clinical side of things and that support. And I think it, as was mentioned, it depends on that background, that experience of that APP coming in. So clinically for me, it's been easier from in, and again, it goes back to that supervision, that observation piece, depending on the clinical setting and where in which that APP is going to practice. So for me personally, helping to onboard our most recent NP who had background as a bedside nurse and was going to provide some inpatient coverage, we spent a lot more time talking about the generating the plan of care and just like ordering things, because that was new for our NP, not receiving those, but creating those orders and creating the plan, and then being communicating as the team leader on the inpatient setting. So clinically for me, that was, I think it depends on the clinical settings of the patient. I think there's a difference of the academic support. Am I coming through okay? Okay, yeah. So the academic support, that's something else, as Dr. Apcom mentioned, talking about the CME for the providers. There's different support that our hospital, I'm sure all the hospitals and programs have some variability here, but we provide different support for our residents and fellows and attendings in terms of academically, in terms of CME, in terms of grants and scholarships to pursue further education, obviously to satisfy the continuing education requirements. And that's on the physician side, but I find within the hospital, we have our kind of our physician side and then our nursing side of things as well. And we want to support within our division of physical medicine and rehabilitation, we wanna support all of our team members. And so for our APPs, some of that support, we've got to reach outside of our, at least what I'm used to on the physician side of things and look at what's available from a nursing perspective throughout our hospital. Being based in an acute care hospital, there are benefits and grants and things that can be done through the nursing side of things. And then we try to encourage our APPs to pursue those opportunities as well. So again, I look at it as separate kinds of support, like the clinical side, which I know we've been talking quite a bit about, as well as that academic and advancement portion as well. Great. Do the APPs receive the same amount of clinic support as physician providers within your practice? Dr. Burton, we can start with you. Yeah. So I think that, yeah, for the most part, absolutely. We have our APPs are in the same clinical settings. So whether it's our clinic coordinators or the clinic nurses or the patient care technicians, that kind of support is the same for all of our providers. I think where it varies, where we have the one difference is the other physician support. Whereas an attending physician may have the resident or that fellow physician rotating with them, our APP might not have that support. It depends on the level of supervision that we're providing. Obviously, if the APP is working one-on-one with an attending physician, then that level of support for me is the same. But if that APP is in a setting where they're independently practicing, we do as much as we can to provide the same amount of clinic support. I think it just varies in terms of that academic, I guess that additional academic support in terms of the residents and fellows is different potentially between our APPs and our attending providers. On the flip side, obviously, we actually have, with our APPs, we are fortunate enough to have some of the students on the NP side of things. Now, we haven't yet worked with PAs in our specific division, but one of the local schools, we have some students who are NP students have the opportunity to rotate with some of our APPs and that provides support. So I think it's somewhat parallel how those students and those trainees support the clinic staff. But on the whole, the level of support is pretty similar. Dr. Afghan? I think it's a great question, Caitlin. And initially, I thought the answer was yes. I did not realize when I had recruited the first APP when I was at Seattle Children's, I just assumed that this person was gonna be getting the same level of support in terms of RN and MA support. And it turned out it wasn't true that the hospital did support the APPs at that time differently with less RN support. They did have an MA rooming the patient, but that support in the clinic setting just was not at the same level. So my answer to that is yes, the APPs do and always should have the same level of support in the clinic setting, whether again, it's MA support or RN support, support through social work or case management. I see the APPs in our practice as providers just like the physician providers. As Justin said, the academic piece was a little different. With medical education is a little bit different, but in terms of the clinical responsibilities, they really are the same. So should have the same level of support from the hospital. In terms of academics, are advanced practice providers members of your faculty? And if they are, do they have the same academic requirements and expectations as physicians do? Dr. Burton, we could start with you. Yes, so I think that this is another area where I see more of a difference between the physician side of things and the nursing side of things. So for our three advanced practice providers, one of them is considered member of our faculty and that specific APP has a doctorate. So it's a DNP and in my experience at Children's here in DC, that's almost the delineation. And so for those APPs, and that's not true, obviously just of my division, but of all the divisions within our hospital. So if that nurse practitioner were to receive that education and that certification, then they become a member of the faculty. Otherwise, I see that the rest of the APPs go up through the, are kind of the nursing ranks. And so there is a delineation there between the faculty, which I think I'll use the word unfortunately creates a delineation in terms of incentive and goal production, whereas faculty at our hospital are our incentive goal program. And so for that advanced practice provider, we actually are required to, and I enjoy, but we're required to set goals just as I do with every faculty member, whereas APPs without that certification, it's a different scenario. Dr. Apkon. The two systems I've worked in were different and are different. And so I think for a rehab physician who's going into, you know, having a discussion about bringing on APPs in an academic environment, it's gonna be important to know who hires the APP and what the expectations are. So in one setting I was in, the APP was hired by the hospital and so it's not considered faculty. And so the promotions track and so forth was just not available to them. Where I am currently at Children's Colorado, the nurse practitioners or APPs are part of our faculty. So they are part of the Department of Physical Medicine and Rehabilitation at University of Colorado School of Medicine. APPs in our department have come on as instructors. And so the rigor around promotion track is very different. So as our physicians come on along the promotion track as an assistant professor, and then moving on, there's certain expectations around applications and research and participation locally and at national levels. But that expectation when you come on as an instructor, as our APPs do, is not there. It doesn't mean that they don't have that opportunity. And if they are interested or motivated, not only can they participate, but they can also participate in the regular promotions track and be promoted along the assistant to associate professor level. So again, it really is a university dependent, it's hospital dependent. And I think as an APP coming into that position, it would be important for him or her to know what those expectations are so that they can meet them successfully. Great, thank you both so much for your answers and your insight. As we talked about in the beginning of the presentation, the goal of this presentation is really to sort of get the word out there and get people's experiences out there to increase APP participation within the academy. So I think I can speak for everyone involved in this presentation in saying, any collaborative efforts between a physician and an APP are possible, but they certainly may vary. So as we sort of venture into this new horizon of more APP involvement within the field of rehab medicine, keeping those things in mind are both critical and important to the success of the model. Thank you both so much. Thank you, Caitlin.

Caitlin Brady

nurse practitioner

Physical Medicine and Rehabilitation

advanced practice providers

scope of practice

COVID-19

pediatric nurse practitioner

onboarding

supervision

academic support