Incorporating Nurse Specialists Into Hematology Care: Improved QOL for Patient and Provider

During the ASH Practice Partnership lunch, Joseph Alvarnas, MD, from the City of Hope, and editor-in-chief of Evidence-Based Oncologyâ„¢ moderated a panel discussion on the impact of including nurse practitioners, physician assistants, and clinical nurse specialists into hematology care.

ON THE SECOND DAY

of the 58th Annual Meeting & Exposition of the American Society of Hematology (ASH), Joseph Alvarnas, MD, chaired the ASH Practice Partnership lunch. Alvarnas, director of Value-Based Analytics and director of Clinical Quality for the Alpha Clinic for Cell Therapy and Innovation, City of Hope, Duarte, California, also serves as editor-in-chief of Evidence-Based Oncology™. The topic of discussion was the impact of including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) into hematology care.

As the care delivery model continues to evolve, the roles of NPs, PAs, and other CNSs who care for patients with hematologic diseases is growing. Although some practices work to ensure that these professionals come together as a team, many can be more efficient. For this particular session, Alvarnas was joined by Marc Zumberg, MD, professor of medicine and section chief, Benign Hematology, University of Florida, Gainesville, Florida; Clayton Hunter, PA-C, physician assistant, University of Florida, Gainesville, Florida; H. Jean Khoury, MD, professor and director, Division of Hematology, Department of Hematology and Medical Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia; and Brittany Hill, PA-C, MMSc, MSc, MPH, physician assistant, Department of Hematology and Medical Oncology, Winship Cancer Institute.

Zumberg shared best practices at their clinic at the University of Florida. “PA training is very exhaustive and rigorous, similar to an MD degree,” he told the audience. “They have to maintain [continuing medical education] credits throughout their career. APRNs, or advanced practice registered nurses, [also] may have specializations, but they spend as much time as MDs, in the clinic,” Zumberg said. APs can improve patient access, support physicians in the clinic, and help physicians achieve a better work-life balance, according to Zumberg.

“APs have prescribing privileges, and they can conduct patient visits. However, there could be some statewide differences,” he said. Zumberg described 3 different models that can be used in practice:

Independent model, where the AP sees patients independently
Shared-visit model, where the patient is seen together with the physician
Mixed-visit model, which is a combination of the above

“A 50% increase in demand for oncologists is expected by 2020, but the number of oncologists is decreasing,” Zumberg said. This is further complicated by the fact that there’s been an 81% increase in survivors and those newly diagnosed with cancer, which demands a boost in the workforce.

Zumberg then shared the results of a study¹ initiated by the American Society of Clinical Oncology to conduct a national survey of integrating nonphysician practitioners (NPPs) and identifying collaborative practice models and services provided by NPPs. The study concluded that NPPs in oncology practices increase productivity for the practice and provide high physician and NPP satisfaction. Ninety-eight percent of patients were aware when care was provided by an NPP, and 92% reported being very satisfied with all aspects of the collaborative care that they received.

“I think incorporating APs is beneficial to the practice. It im proves access to care, improves care continuity, and APs have a more holistic approach to patient care,” Zumberg said, adding that physicians can benefit as well since they can now include more patients in the practice and reserve their time for the more complex patients. “Additionally, APs can improve the quality of life and work-life balance for MDs” he added.

Khoury described the model that is being practiced at the Winship Cancer Institute. “We have 70 APs at our clinic, and the model is patient- and caretaker-centered. The hematologist meets with new and complex patients, establishes and adapts treatment plans, and communicates changes to patients and the referring physician.” The nurse coordinator, Khoury told the audience, has a very important role to play and is the main point of contact between the patient and the practice.

The AP functions independently and in parallel with the MD, implements and reinforces treatment plans, and flags events that require a physician intervention. “In addition to the AP, the care team includes a social worker, nurse coordinator, pharmacist, and the physician, of course,” he added. “Our model is functional because we hold a pre-clinic meeting between the physician, the advance practice provider (APP), and the NP. The physician and APP have independent schedules—the physician develops a very clear care plan through notes, with the patient’s expectations set at the first visit,” said Khoury.

Hill described a typical APP schedule, which includes an average of 3 clinic days each week. “We also teach APP students, attend research meetings, and there’s a continuing education clinic,” she said. “Our in-patient model includes a team of 2 APPs in the hematology consult service.” A very structured day is responsible for the model’s successful implementation in the clinic, as is communication with the primary care team. “A similar model is followed in the inpatient leukemia and bone marrow transplant services,” Hill added. Describing the integral role of the APP in the care team, she told the audience that the APP interacts with the patient and family members and holds end-of-life discussions as well.

Alvarnas asked the panelists, “As we think about value in healthcare, the theoretical construct of the triple aim, and creating a practical workflow, how do we blend them together?”

“A lot of these developments were associated with fellowship students and physician work hours,” said Zumberg. “The traditional academic model of residency fellows was crumbling for us, so that when the APs came in, the institution saw an advantage in this. Over the years, the fellows have shifted their clinic time to cater to outpatient care and new consults.”

“Taking on fresh students is a huge investment for physicians … they need to devote a significant amount of their time up front in training them,” Hill said. “For me, personally, the learning curve was very steep during the first few months, but we continue to learn every single day.” An important part of the process “is an open channel of communication between the AP and the physician,” Hill emphasized. “There is need for flexibility and communication.” REFERENCE

Towle EL, Barr TR, Hanley A, Kosty M, Williams S, Goldstein MA. Results of the ASCO study of collaborative practice arrangements. J Oncol Pract. 2011;7(5):278-282. doi: 10.1200/JOP.2011.000385.