- Email: [email protected]
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Seminars in Oncology Nursing, Vol 31, No 4 (November), 2015: pp 282-289
ESTABLISHING AN ADVANCED PRACTICE NURSING CLINIC IN THE CANCER SETTING KALA BLAKELY AND DIANE G. COPE OBJECTIVES: To explore the roles of the Advanced Practice Nurse (APN), specifically the Nurse Practitioner (NP) in oncology and the issues, resources, and planning involved in establishing an NP clinic in the cancer setting.
DATA SOURCES: Published peer reviewed literature, web-based resources, and cancer-related professional resources.
CONCLUSION: The number of cancer patients is increasing and demands for oncology services are rising. With a shortage of oncologists projected over the next decade, the oncology NP can play a key role in providing oncology services across the cancer continuum.
IMPLICATIONS
FOR NURSING PRACTICE: Oncology APNs in the role of Nurse Practitioner (NP) can facilitate and enhance the delivery of oncology care. Traditional and innovative opportunities exist for the NP including the establishment of a NP clinic in the cancer setting; ultimately providing needed oncology services and quality care for patients with cancer.
KEY WORDS: Advanced practice Nurse, APN, Nurse Practitioner, oncology, cancer symptom management ver the next four decades, several changes in the demographics of the United States are predicted that will dramatically affect health care. The number of individuals aged 65 and over will more than double by 2050, with the 85 and older Kala Blakely, DNP, CRNP, NP-C: Instructor, School of Nursing, The University of Alabama at Birmingham, segment of the population expected to triple to Birmingham, AL. Diane G. Cope, PhD, ARNP, BC, 19 million.1 Similarly, the number of minorities AOCNP: Oncology Nurse Practitioner, Florida Cancer will double to 241.3 million by 2060 and will Specialists and Research Institute, Fort Myers, FL. comprise 57% of the population.2 The passage of Address correspondence to Diane G. Cope, PhD, the Affordable Care Act will enable approximately ARNP, BC, AOCNP, Oncology Nurse Practitioner, 34 million of the currently uninsured 50 million Florida Cancer Specialists and Research Institute, Americans the ability to receive health insurance 15681 New Hampshire Ct., Fort Myers, FL 33908. coverage with increased demand for health care e-mail: [email protected] services. Additionally, the health care workforce Ó 2015 Elsevier Inc. All rights reserved. is aging and retiring and physician shortage projec0749-2081/3104-$36.00/0. tions are expected to reach 91,500 by 2020.3 http://dx.doi.org/10.1016/j.soncn.2015.08.004
O
ESTABLISHING AN APN CLINIC IN THE CANCER SETTING
Clearly, health care delivery will require new practice models to meet the expanding patient population. Advanced practice nurses, specifically nurse practitioners (NPs), possessing advanced education, can play a key role in the provision of health care. The Institute of Medicine report ‘‘The Future of Nursing: Leading Change, Advancing Health’’ recommended state and federal level changes that would allow NPs to practice to the full extent of their education.4 The specialty of oncology is also projected to have a shortage of oncologists with increasing demands for oncology services. The aging population, with individuals over the age of 65 having the greatest incidence of cancer, the increasing number of cancer survivors, and the slower growth in the supply of oncologists will challenge the delivery of oncology care.5 By 2020, demand for oncology services are projected to increase by 48%; however, there will only be a 14% increase in the number of oncologists, resulting in a shortage of 2,550 to 4,080 oncologists.5 Several strategies have been suggested to offset this deficit, yet not one strategy will be sufficient to meet future demands. These strategies include increasing the number of fellowship positions, having primary care physicians assume care of the cancer patient in remission, improving health delivery resources, and increasing the use of NPs or physician assistants (PAs). The use of NPs/PAs has been found to have several advantages in the oncology setting. Results from the Association of American Medical Colleges Center for Workforce Studies survey of clinical oncologists6 that included a random sample of 4,000 oncologists found that oncologists who were currently working with NPs/PAs (56%) reported higher weekly visit rates than those who did not. Other reported advantages of working with NPs/PAs were improved practice efficiency, increased time to spend on complex cases and participate in clinical research, increased professional satisfaction, and improved overall patient care. Of the 56% of oncologists who worked with NPs/PAs, 30% utilized NPs/PAs for traditional practice activities that included patient education and counseling, pain and symptom management, and patient management between visits. The other 26% utilized NPs/PAs for advanced practice activities such as assisting with new patient consults, ordering routine chemotherapy, performing research activities and invasive procedures, and providing end-of-life or hospice care. Unequivocal
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benefits exist with the use of NPs/PAs in oncology care; however, further research is needed to define efficient practice roles and responsibilities.
NURSE PRACTITIONER ROLES IN CANCER CARE Historically, the NP role was first conceptualized in 1965 with the creation of a pediatric NP program at the University of Colorado.7 Beginning role functions included health assessment, differential diagnosis, pharmacologic treatment of acute and chronic illnesses, patient education and counseling, and health promotion and disease prevention in public health nursing. However, today the traditional role has expanded to include a broader range of responsibilities. According to the American Association of Nurse Practitioners’ Standards of Practice for Nurse Practitioners,8 the NP obtains health and medical histories, performs physical examinations, orders preventative and diagnostic procedures, identifies health and medical risk factors, analyzes collected data, formulates a differential diagnoses, orders and interprets additional diagnostic tests, orders pharmacologic and nonpharmacologic therapies, develops a patient and family education plan of care, and reassesses and modifies the treatment plan of care. In addition, the NP participates as a team leader and member of the medical care team, educator, researcher, and consultant. Only a very small percentage of NPs/PAs have practiced in oncology over the past 30 years.9,10 Currently, it is estimated that 2.4% of PAs and 1% of NPs are employed in oncology.11 However, the NP in oncology has numerous role possibilities, both traditional and innovative, based on their education. The oncology NP, initially practicing in palliative care in the early 1990s, has expanded care of patients with cancer to multiple settings along the cancer continuum. The foundation of this care mimics the traditional role functions in primary care, but also displays a sound knowledge base of the specialty of oncology. A key role intertwined in these activities is symptom management of the patient undergoing therapy. The oncology NP, possessing advanced education and knowledge of oncology, can utilize advanced assessment skills with appropriate diagnostic testing and develop differential diagnoses with a plan of care specific to the cancer diagnosis and oncologic therapy being administered, and can provide medical and nursing care for the signs
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and symptoms of potential toxicities that a patient may be experiencing during therapy. Ultimately, an oncology NP can assist in enhancing quality of life, preventing treatment regimen delays or dosage reductions, and avoiding more serious physical complications and hospitalizations. Limited research investigating NP symptom management clinics have been relatively favorable. Mason and colleagues12 evaluated a weekly NP-managed symptom management clinic for patients with head and neck cancer treated with chemoradiotherapy. Outcome measurements included number of visits during treatment, hospitalization rates, and rate of chemotherapy dose deviations between the prechemotherapy clinic group that received written and verbal education prior to starting therapy and one visit in the middle of radiation therapy compared with the NP-led clinic group that included weekly visits for physical examination and assessment of treatment toxicity. Results indicated that the weekly NP-led clinic group compared with the pre-chemotherapy clinic group had greater reduction in hospitalization rates (12% vs 28%), chemotherapy dose deviation rates (6% vs 48%), and greater completion rates of the full seven scheduled doses of chemotherapy (90% vs 46%). Further, support for NP symptom management clinics is provided by Ruegg,13 describing the establishment of a NPled urgent care center at the Ohio State University Comprehensive Cancer Center. Data were collected over a 6-year period to assess reasons patients with cancer sought medical attention. The top five reasons at the initiation of the clinic were dehydration (35%), acute pain (17%), anemia (12%), nausea and vomiting (11%), dyspnea (10%), and fever (6%). During the final year of data collection, the top five reasons were dehydration (29%), dyspnea (12%), pain (12%), gastrointestinal complaints (10%), and fever (5%). Similar study findings were noted on use of the emergency department by patients with cancer.14-17 Ruegg13 concludes that the NP-led urgent care clinic may provide an alternative to acute care of the patient with cancer and decrease expensive emergency department visits and potential hospitalizations. Conversely, Sivendran et al18 found no reduction of emergency department utilization among patients with cancer with the establishment of a NP-staffed symptom management clinic. The authors concluded that other factors, such as standard symptom
assessment and management, patient and caregiver education, and improved coordination with supportive services may need to be incorporated at the cancer institution. Further randomized studies are needed; however, NP-led clinics present innovative opportunities for state-of-theart clinical cancer care, not only with symptom management but also other care specific clinics such as genetics and survivorship.
HOW TO ESTABLISH AN NP CLINIC Many factors need to be considered when establishing an NP-run clinic. The communities being served, needs of the patient population, and the services currently available in that area all contribute to creating a clinic that can be selfsustaining. For many years, there have been concerns about the decrease in general physicians impacting the primary provider shortage. The National Governors Association reported that there has been a steady decline in the number of medical students going into primary care.19 Additionally, the baby boomers are becoming of age where the need for general providers is growing faster than the number of physicians going into this field of practice. A void has been opened and can be filled by the second ranked best career in the US, NPs.20 The idea that NPs can be employed to balance out the general practitioner deficit is not secret knowledge. In fact, the Affordable Care Act allotted 15 million dollars in funding for nurse-managed health clinics.21 Thus, national leaders have recognized the leadership abilities of NPs. Physical location and the needs of the community must be evaluated when determining the benefits of having an NP-run clinic. The Center for Medicare and Medicaid Services regularly provide updates of areas designated as having health care provider shortages and communities that are considered rural.22 Opening a clinic in either of these settings places the NP in a publicly reported location of need. Along with determining the geographic need, assessing the specific needs of the patient population is imperative. For example, some rural populations do not have access to care within a 50-mile radius of their community. The geographic need would be for an NP-run clinic in closer proximity to the community. Other populations might have several internal medicine practices, but may lack a clinic to
ESTABLISHING AN APN CLINIC IN THE CANCER SETTING
care for the pediatric population. Some clinics prefer to focus care on preventive services, while other clinics focus on the acute care of patients and/or refer back to a primary care provider for continuing care. Dependent upon the population, the NP-run clinic should weigh the pros and cons of having a specialized NP in the clinic. The number of clientele needing specialty services must, at a minimum, be equivalent to the cost of employing the specialized NP. Table 1 provides the average salaries for NP specialties.23-27 The needs of the population must be met in order for the NP clinic to be successful. A needs assessment must consider the services currently available in the area and the distance to the nearest services most frequently needed by the population. Once a list of selected services is created, one must take into account the feasibility of meeting these demands. Next, rank the services and supplies needed by priority, with the greatest need ranked highest. For example, stocking the lab with blood draw equipment may take priority over x-ray equipment when forming a primary care clinic. As the clinic opens and has monetary funds coming in, higher-cost expenditures can take place. Credentialing and reimbursement are not guaranteed with insurance companies at the opening of the clinic; therefore, focus should be placed on the clinic’s immediate needs. Formation of the NP-run clinic is a multiple step process (Table 2). It is necessary to take financial considerations into account when deciding whether a clinic will be for-profit or non-profit. The clinic will require a monetary base to properly establish the foundational needs, such as medical equipment and office supplies. Non-profit clinics often use grant funds. Grant funding may specify exactly what is expected of the clinic, including location and every service provided. For-profit
TABLE 1. Average Salaries for Nurse Practitioner (NP) Specialties Specialty 23,27
Family NP Gerontology NP24 Pediatric NP26 Psychiatric NP24,25,27 Orthopedic NP25 Pediatric Endocrinology NP25 Cardiology NP24 Oncology NP24
Average Salary $83,984 $94,485 $82,101 $88,000 – $92,396 $70,000 – $90,000 $70,000 – $90,000 $90,370 $90,862
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TABLE 2. Formation of an NP Clinic Steps to Take
Tips on Decision Making
Determine the type of venture
Establish a business entity
Select a location for the practice
Obtain licenses and insurance
Decide whether this will be an individually owned business or a partnership, this will help in deciding what type of business entity to form Consult with an accountant and attorney to determine which type of legal entity to form (such as LLC, S Corporation, or C Corporation) After researching the needs of the community, seek out office space that will meet the business needs of the practice Business licenses – city, county, state Lab license - Clinic Laboratory Improvement Amendments (CLIA) license or waiver, depending on the extent of lab testing to be performed in the clinic Physician and NP Collaborative Agreements – dependent upon State of practice Insurances – coverage for the NP malpractice insurance, along with the other employees in the clinic
clinics have more liberty to decide what services may or may not be offered within the clinic. Next, determine the type of venture in which the business will function, such as a sole proprietorship or a corporation. Once the type of business has been selected, a Certificate of Formation will need to be filed with the state to record the business as a legal entity. At this point, the clinic lease can be secured in the business name. The municipalities in which the practice is located will require licensing. Insurance to cover the property and provider will also need to be acquired. Simultaneously, the NP and physician should establish their Collaborative Agreement required by the state; thus, allowing for the credentialing application process to begin.
NP REGULATIONS In the US, NPs must practice within their scope of certification and regulation. For a registered
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nurse (RN) to obtain an NP license the RN must first complete the necessary degree requirements and pass an examination from a national certifying body. Currently, there are two national certifying bodies, the American Nurses Credentialing Center (ANCC) and American Academy of Nurse Practitioners (AANP). The RN will take the examination that is specific to the NPs degree program of study. NPs are also governed on a state-by-state basis.28 From a business perspective, the business licenses required for an NP-run clinic are regulated by the city, county, and state. Dependent on the location of the clinic, some municipalities only require a license for the business, not the NP. It is imperative to review the legal requirements for licensing based on the physical location of the clinic. Along with the business license, it is important for NPs to keep professional licenses up-todate with the state nursing board. The NP must also maintain national certification with either ANCC or AANP. Each state has a Nurse Practice Act that sets forth the rules for licensure, education, scope of practice, and rules for disciplinary action.29 At this time, there are 20 states that allow NPs to practice in a full scope of practice.28 This type of practice allows NPs to practice independently of physicians. A limited scope of practice requires the NP to practice in collaboration with a physician under a set of specified guidelines based on regulations set by the NPs’ state board of nursing and/or the state medical board. There are currently 19 states that practice under this limited scope.28 The remainder of US states allow NPs to practice under a restricted scope, which prevents any independent practice by the NP (see Table 3).28 There may be additional certifications required for the NP to treat patients to the fullest scope of practice. For example, in Alabama, NPs that desire the legal ability to write prescriptions for controlled substances must apply for a Qualified Alabama Controlled Substances Certificate (QACSC).30 After approval of the QACSC, the NP may then apply for a Drug Enforcement Administration license that allows for an NP to prescribe controlled substances based on the legal limits of the State of Alabama.30 The NP may also seek advanced certification to further the knowledge base, such as nurse executive or nursing professional development.31,32
TABLE 3. State NP Scope of Practice
Full Practice Alaska Arizona Colorado Connecticut District of Columbia Hawaii Idaho Iowa Maine Minnesota Montana Nebraska Nevada New Hampshire New Mexico North Dakota Oregon Rhode Island Vermont Washington Wyoming
Reduced Practice
Restricted Practice
Alabama Arkansas Delaware Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi New Jersey New York Ohio Pennsylvania South Dakota Utah West Virginia Wisconsin
California Florida Georgia Massachusetts Michigan Missouri North Carolina Oklahoma South Carolina Tennessee Texas Virginia
NEGOTIATING THE ROLE OF THE PHYSICIAN The role of the physician in an NP clinic must be determined based on the needs of the clinic, the desires of the physician, and each state’s specific NP Scope of Practice. The role of the physician varies dependent upon how involved the physician would like to be in the clinic. Three NP clinics were asked about the roles the collaborating physicians have in their practices. The first clinic is a primary care clinic run with one NP and two office personnel to assist. The NP pays her collaborating physician a flat fee of $5.00 per patient visit each month. The physician is present 1 day a week for 8 hours. He reviews the designated number of patient charts set by the Board of Nursing collaborative requirements, consults with the NP on complex patients, and otherwise is not involved in direct patient care. The second clinic has a physician that prefers no involvement in patient care. The physician reviews the minimal required number of patient charts and is paid a flat monthly fee regardless of the number of patients seen by the NP. The third clinic also has a physician whom chooses no patient involvement.
ESTABLISHING AN APN CLINIC IN THE CANCER SETTING
The physician goes to the clinic 1 day a week for chart review and consultation with the NP. This clinic has an agreement with the physician to pay him $5.00 per patient visit or $1,500 per month, whichever is the lessor of the two. As illustrated, there are numerous ways to establish the role and payment of a physician in an NP-run clinic. A first step is to determine the involvement of the physician with the clinic. Some physicians desire to be involved and want to provide patient care, while other physicians may choose to have no direct contact. When negotiating the fee for the physician, take into account the time commitment required of the physician, expertise, and if the physician is providing patient care. There should be a legal contract between the NP and physician that identifies the expectations of both parties to ensure that all involved are in agreement and working toward the same goal of quality patient care.
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agreement with the NP of what rate the NP will be reimbursed for services provided. Because NPs are caring for patients in a primary care setting to the fullest scope of practice, the same payment for services does not translate from the insurers to the NPs. Medicare currently reimburses qualified, credentialed NPs at a rate of 85% of what physicians would be reimbursed for the same services.33 Naylor and Kurtzman34 noted that NPs are often reimbursed 75% to 85% in comparison to the 100% physician reimbursement rate. The reduced rate of payment seems nominal until the NP notices that some private insurers have an extremely low reimbursement rate for NPs at a mere 55%. The credentialing process and reimbursement should be thoroughly researched when forming an NP-run clinic and financial decisions should be based on what population and services will be provided in the clinic.
REIMBURSEMENT CONSIDERATIONS
ADVANCED PRACTICE NURSING IN THE MEDICAL ONCOLOGY PRACTICE
It is necessary to begin the billing (credentialing) process before an NP-run clinic has opened the clinic. Credentialing is the process of verifying that a professional has the education and licensure that is claimed on a professional’s curriculum vitae and that the same professional can legally carry out the practices billed to health insurance companies for reimbursement.32 Some medical insurance companies have a rigorous credentialing process for medical providers that can take up to 120 days to complete. One nationally known insurance carrier requires not only the NP to become credentialed, but also requires the NP’s collaborating physician to be credentialed with the insurer. The task of completing credentialing has often been compared with the same amount of paperwork required to obtain a house mortgage. While the mountain of paperwork may seem daunting, this is a task that must be completed to receive reimbursement for medical services rendered to patients. One might also research all the major medical insurance companies to determine which insurance companies will allow for direct billing by NPs. Even with the recognition of NPs nationally, numerous insurance companies do not allow for credentialing of NPs and will not pay the professional for medical services provided. As credentialing comes to completion, the individual insurance companies will often solicit an
Although NPs are practicing in various oncology settings, most NPs are employed in the outpatient clinic with approximately 80% of patients undergoing treatment in the ambulatory setting.35 Previous research has documented clinical productivity for oncologists working with PAs and NPs, including increased efficiency and physician satisfaction, improving overall care, and increasing physician time for complex cases and research.6 Little is known, however, regarding practice productivity and efficient practice models as a result of differing utilization of NPs in oncology and the variance in state scope-of-practice laws that determine NP services and the extent of independent practice. Buswell et al36 evaluated productivity, revenue, and provider and patient satisfaction utilizing three practice models in an oncology ambulatory practice. The three practice models included: the independent visit model, defined as physicians, NPs, and PAs functioning independently for two thirds or more of their patients; the shared visit model, defined as physicians, NPs, and PAs seeing two thirds of their patients together; and the mixed visit model, defined as physicians and midlevels seeing patients together and independently. Results indicated that overall productivity and visit fees were similar in the three models and provider and patient satisfaction were high in all models. Further research is
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needed to evaluate quality of care, patient and provider satisfaction, productivity, and cost, ultimately defining an efficient care model for physicians, NPs, and PAs in the oncology setting.
CONCLUSION With the aging population and increased incidence in cancer, the increasing numbers of cancer survivors, the aging of the health care workforce,
and the projected shortage of oncologists, NPs can play a key role in caring for patients with cancer. The NP has many opportunities and role functions, both traditional and innovative, in the cancer clinical setting and can contribute to the cancer care team’s delivery of quality oncology care. These opportunities can be embraced by NPs taking the steps to establish NP-run clinics. The clinics can then fulfill the needs of the patient population and provide a high-quality standard of care that will better the patients’ health.
REFERENCES 1. Vincent GK, Velkoff VA. The next four decades: the older population in the United States: 2010 to 2050. Available at: http://www.census.gov/prod/2010pubs/p25-1138.pdf (accessed January 8, 2015). 2. US Census Bureau. 2010 census data. Available at: http:// www.census.gov/2010census/data/ (accessed January 8, 2015). 3. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med 2012;63:435-445. 4. Institute of Medicine. The future of nursing: leading change, advancing health. Available at: http://www.thefutureof nursing.org/sites/default/files/Future%20of%20Nursing%20Re port_0.pdf (accessed July 9, 2015). 5. Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand of oncologists. JOP 2007;3:79-86. 6. Association of American Medical Colleges. Forecasting the supply of and demand for oncologists: a report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. Available at: http://www.asco.org/workforce (accessed January 15, 2015). 7. Murphy-Ende K. Advanced practice nursing: reflections on the past, issues for the future. Oncol Nurs Forum 2002; 29:106-112. 8. American Association of Nurse Practitioners. Standards of practice for nurse practitioners. Available at: http://www.aanp. org/images/documents/publications/standardsofpractice.pdf (accessed July 2, 2015). 9. Maxwell MB. Nurse practitioner chemotherapy clinic. Cancer Nurs 1979;2:211-218. 10. Yeung KY, Maxwell V. The training and role of the physician assistant in oncologic practice. PA J 1976;6:190-192. 11. Polansky M, Ross AC, Coniglio D. Physician assistant perspective on the ASCO Workforce Study regarding the use of physician assistants and nurse practitioners. JOP 2010;6:31-33. 12. Mason H, DeRubeis MB, Foster J, Taylor JM, Worden FP. Outcomes evaluation of a weekly nurse practitioner-managed symptom management clinic for patients with head and neck cancer treated with chemoradiotherapy. Oncol Nurs Forum 2013;40:581-586. 13. Ruegg TA. A nurse practitioner-led urgent care center: meeting the needs of the patient with cancer. Clin J Oncol Nurs 2013;17:E52-57. 14. Barbera L, Taylor C, Dundgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;182:563-568.
15. Bozdemir N, Eray O, Eken C, Senol Y, Artac M, Samur M. Demographics, clinical presentations, and outcomes of cancer patients admitted to the emergency department. Turk J Med Sci 2009;39:235-240. 16. Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol 2011; 29:2683-2688. 17. McKenzie H, Hayes L, White K, et al. Chemotherapy outpatients’ unplanned presentations to hospital: a retrospective study. Support Care Cancer 2011;19:963-969. 18. Sivendran S, Holliday R, De La Torre K, Newport KB. Impact of a nurse practitioner staffed, symptom-management clinic on emergency department utilization in a large community oncology cancer institute. J Clin Oncol 2014;32(Suppl 31). abstr 58. 19. Schiff M. The role of nurse practitioners in meeting increasing demand for primary care. Available at: http://www. nga.org/cms/home/nga-center-for-best-practices/center-publi cations/page-health-publications/col2-content/main-contentlist/the-role-of-nurse-practitioners.html (accessed July 9, 2015). 20. US News & World Report. Best health care jobs: nurse practitioner. Available at: http://money.usnews.com/ careers/best-jobs/nurse-practitioner (accessed February 14, 2015). 21. Cooper K. Affordable care act nurse managed health clinics (NMHC). Available at: http://bhpr.hrsa.gov/grants/ nursemangfaq.pdf (accessed January 30, 2015). 22. US Department of Health and Human Services, Health Resources and Service Administration. Find shortage areas: HPSA by state and county. Available at: http://hpsafind.hrsa. gov/ (accessed January 28, 2015). 23. PayScale. Family Nurse Practitioner (NP) Salary (United States). Available at: http://www.payscale.com/research/US/ Job¼Family_Nurse_Practitioner_(NP)/Salary (accessed July 2, 2015). 24. Midlevel U. Top 10 highest paying nurse practitioner specialties. Available at: http://www.midlevelu.com/blog/top10-highest-paying-nurse-practitioner-specialties (accessed July 2, 2015). 25. Health eCareers. Top 10 highest paying nurse practitioner jobs. Available at: http://www.healthecareers.com/article/top10-highest-paying-nurse-practitioner-jobs/171162 (accessed July 2, 2015).
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26. Graduate Nursing EDU (n.d.). How to become a pediatric nurse practitioner. Available at: http://www.graduatenursingedu. org/pediatric-nurse-practitioner/ (accessed July 2, 2015). 27. White S. 5 of the highest paying nursing specialties. Available at: http://www.monster.com/healthcare/a/5-highest-payingnursing-specialities (accessed July 2, 2015). 28. The American Academy of Nurse Practitioners (n.d.). State practice environment. Available at: http://www.aanp.org/ legislation-regulation/state-legislation-regulation/state-practiceenvironment (accessed February 2, 2015). 29. National Council of State Boards of Nursing (n.d.). Nurse practice act, rules and regulations. Available at: https://www. ncsbn.org/nurse-practice-act.htm (accessed February 10, 2015). 30. Alabama Board of Medical Examiners & Medical Licensure Commission (n.d.). Frequently asked questions – QACSC for CRNPs and CNMs. Available at: http://www.albme.org/faqqacscnp.html#qu1 (accessed February 10, 2015). 31. American Nurses Credentialing Center (n.d.). Credentialing definitions. Available at: http://www.nursecre
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dentialing.org/CredentialingDefinitions (accessed February 1, 2015). 32. American Nurses Credentialing Center (n.d.). ANCC certification center. Available at: http://www.nursecredentialing. org/certification.aspx (accessed February 9, 2015). 33. Reimbursement Task Force and APRN Work Group, of the WOCN Society National Public Policy Committee, 2011. Reimbursement of advanced practice registered nurse services: a fact sheet. J Wound Ostomy Continence Nurs 2012;39: S7-S16. 34. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff 2010;29:893-899. 35. Williamson TS. The shift of oncology inpatient care to outpatient care: the challenge of retaining expert oncology nurses. Clin J Oncol Nurs 2008;12:186-189. 36. Buswell L, Ponte PR, Shulman LN. Provider practice models in ambulatory oncology practice: analysis of productivity, revenue, and provider and patient satisfaction. JOP 2009;5:188-192.
Seminars in Oncology Nursing, Vol 31, No 4 (November), 2015: pp 282-289
ESTABLISHING AN ADVANCED PRACTICE NURSING CLINIC IN THE CANCER SETTING KALA BLAKELY AND DIANE G. COPE OBJECTIVES: To explore the roles of the Advanced Practice Nurse (APN), specifically the Nurse Practitioner (NP) in oncology and the issues, resources, and planning involved in establishing an NP clinic in the cancer setting.
DATA SOURCES: Published peer reviewed literature, web-based resources, and cancer-related professional resources.
CONCLUSION: The number of cancer patients is increasing and demands for oncology services are rising. With a shortage of oncologists projected over the next decade, the oncology NP can play a key role in providing oncology services across the cancer continuum.
IMPLICATIONS
FOR NURSING PRACTICE: Oncology APNs in the role of Nurse Practitioner (NP) can facilitate and enhance the delivery of oncology care. Traditional and innovative opportunities exist for the NP including the establishment of a NP clinic in the cancer setting; ultimately providing needed oncology services and quality care for patients with cancer.
KEY WORDS: Advanced practice Nurse, APN, Nurse Practitioner, oncology, cancer symptom management ver the next four decades, several changes in the demographics of the United States are predicted that will dramatically affect health care. The number of individuals aged 65 and over will more than double by 2050, with the 85 and older Kala Blakely, DNP, CRNP, NP-C: Instructor, School of Nursing, The University of Alabama at Birmingham, segment of the population expected to triple to Birmingham, AL. Diane G. Cope, PhD, ARNP, BC, 19 million.1 Similarly, the number of minorities AOCNP: Oncology Nurse Practitioner, Florida Cancer will double to 241.3 million by 2060 and will Specialists and Research Institute, Fort Myers, FL. comprise 57% of the population.2 The passage of Address correspondence to Diane G. Cope, PhD, the Affordable Care Act will enable approximately ARNP, BC, AOCNP, Oncology Nurse Practitioner, 34 million of the currently uninsured 50 million Florida Cancer Specialists and Research Institute, Americans the ability to receive health insurance 15681 New Hampshire Ct., Fort Myers, FL 33908. coverage with increased demand for health care e-mail: [email protected] services. Additionally, the health care workforce Ó 2015 Elsevier Inc. All rights reserved. is aging and retiring and physician shortage projec0749-2081/3104-$36.00/0. tions are expected to reach 91,500 by 2020.3 http://dx.doi.org/10.1016/j.soncn.2015.08.004
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ESTABLISHING AN APN CLINIC IN THE CANCER SETTING
Clearly, health care delivery will require new practice models to meet the expanding patient population. Advanced practice nurses, specifically nurse practitioners (NPs), possessing advanced education, can play a key role in the provision of health care. The Institute of Medicine report ‘‘The Future of Nursing: Leading Change, Advancing Health’’ recommended state and federal level changes that would allow NPs to practice to the full extent of their education.4 The specialty of oncology is also projected to have a shortage of oncologists with increasing demands for oncology services. The aging population, with individuals over the age of 65 having the greatest incidence of cancer, the increasing number of cancer survivors, and the slower growth in the supply of oncologists will challenge the delivery of oncology care.5 By 2020, demand for oncology services are projected to increase by 48%; however, there will only be a 14% increase in the number of oncologists, resulting in a shortage of 2,550 to 4,080 oncologists.5 Several strategies have been suggested to offset this deficit, yet not one strategy will be sufficient to meet future demands. These strategies include increasing the number of fellowship positions, having primary care physicians assume care of the cancer patient in remission, improving health delivery resources, and increasing the use of NPs or physician assistants (PAs). The use of NPs/PAs has been found to have several advantages in the oncology setting. Results from the Association of American Medical Colleges Center for Workforce Studies survey of clinical oncologists6 that included a random sample of 4,000 oncologists found that oncologists who were currently working with NPs/PAs (56%) reported higher weekly visit rates than those who did not. Other reported advantages of working with NPs/PAs were improved practice efficiency, increased time to spend on complex cases and participate in clinical research, increased professional satisfaction, and improved overall patient care. Of the 56% of oncologists who worked with NPs/PAs, 30% utilized NPs/PAs for traditional practice activities that included patient education and counseling, pain and symptom management, and patient management between visits. The other 26% utilized NPs/PAs for advanced practice activities such as assisting with new patient consults, ordering routine chemotherapy, performing research activities and invasive procedures, and providing end-of-life or hospice care. Unequivocal
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benefits exist with the use of NPs/PAs in oncology care; however, further research is needed to define efficient practice roles and responsibilities.
NURSE PRACTITIONER ROLES IN CANCER CARE Historically, the NP role was first conceptualized in 1965 with the creation of a pediatric NP program at the University of Colorado.7 Beginning role functions included health assessment, differential diagnosis, pharmacologic treatment of acute and chronic illnesses, patient education and counseling, and health promotion and disease prevention in public health nursing. However, today the traditional role has expanded to include a broader range of responsibilities. According to the American Association of Nurse Practitioners’ Standards of Practice for Nurse Practitioners,8 the NP obtains health and medical histories, performs physical examinations, orders preventative and diagnostic procedures, identifies health and medical risk factors, analyzes collected data, formulates a differential diagnoses, orders and interprets additional diagnostic tests, orders pharmacologic and nonpharmacologic therapies, develops a patient and family education plan of care, and reassesses and modifies the treatment plan of care. In addition, the NP participates as a team leader and member of the medical care team, educator, researcher, and consultant. Only a very small percentage of NPs/PAs have practiced in oncology over the past 30 years.9,10 Currently, it is estimated that 2.4% of PAs and 1% of NPs are employed in oncology.11 However, the NP in oncology has numerous role possibilities, both traditional and innovative, based on their education. The oncology NP, initially practicing in palliative care in the early 1990s, has expanded care of patients with cancer to multiple settings along the cancer continuum. The foundation of this care mimics the traditional role functions in primary care, but also displays a sound knowledge base of the specialty of oncology. A key role intertwined in these activities is symptom management of the patient undergoing therapy. The oncology NP, possessing advanced education and knowledge of oncology, can utilize advanced assessment skills with appropriate diagnostic testing and develop differential diagnoses with a plan of care specific to the cancer diagnosis and oncologic therapy being administered, and can provide medical and nursing care for the signs
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and symptoms of potential toxicities that a patient may be experiencing during therapy. Ultimately, an oncology NP can assist in enhancing quality of life, preventing treatment regimen delays or dosage reductions, and avoiding more serious physical complications and hospitalizations. Limited research investigating NP symptom management clinics have been relatively favorable. Mason and colleagues12 evaluated a weekly NP-managed symptom management clinic for patients with head and neck cancer treated with chemoradiotherapy. Outcome measurements included number of visits during treatment, hospitalization rates, and rate of chemotherapy dose deviations between the prechemotherapy clinic group that received written and verbal education prior to starting therapy and one visit in the middle of radiation therapy compared with the NP-led clinic group that included weekly visits for physical examination and assessment of treatment toxicity. Results indicated that the weekly NP-led clinic group compared with the pre-chemotherapy clinic group had greater reduction in hospitalization rates (12% vs 28%), chemotherapy dose deviation rates (6% vs 48%), and greater completion rates of the full seven scheduled doses of chemotherapy (90% vs 46%). Further, support for NP symptom management clinics is provided by Ruegg,13 describing the establishment of a NPled urgent care center at the Ohio State University Comprehensive Cancer Center. Data were collected over a 6-year period to assess reasons patients with cancer sought medical attention. The top five reasons at the initiation of the clinic were dehydration (35%), acute pain (17%), anemia (12%), nausea and vomiting (11%), dyspnea (10%), and fever (6%). During the final year of data collection, the top five reasons were dehydration (29%), dyspnea (12%), pain (12%), gastrointestinal complaints (10%), and fever (5%). Similar study findings were noted on use of the emergency department by patients with cancer.14-17 Ruegg13 concludes that the NP-led urgent care clinic may provide an alternative to acute care of the patient with cancer and decrease expensive emergency department visits and potential hospitalizations. Conversely, Sivendran et al18 found no reduction of emergency department utilization among patients with cancer with the establishment of a NP-staffed symptom management clinic. The authors concluded that other factors, such as standard symptom
assessment and management, patient and caregiver education, and improved coordination with supportive services may need to be incorporated at the cancer institution. Further randomized studies are needed; however, NP-led clinics present innovative opportunities for state-of-theart clinical cancer care, not only with symptom management but also other care specific clinics such as genetics and survivorship.
HOW TO ESTABLISH AN NP CLINIC Many factors need to be considered when establishing an NP-run clinic. The communities being served, needs of the patient population, and the services currently available in that area all contribute to creating a clinic that can be selfsustaining. For many years, there have been concerns about the decrease in general physicians impacting the primary provider shortage. The National Governors Association reported that there has been a steady decline in the number of medical students going into primary care.19 Additionally, the baby boomers are becoming of age where the need for general providers is growing faster than the number of physicians going into this field of practice. A void has been opened and can be filled by the second ranked best career in the US, NPs.20 The idea that NPs can be employed to balance out the general practitioner deficit is not secret knowledge. In fact, the Affordable Care Act allotted 15 million dollars in funding for nurse-managed health clinics.21 Thus, national leaders have recognized the leadership abilities of NPs. Physical location and the needs of the community must be evaluated when determining the benefits of having an NP-run clinic. The Center for Medicare and Medicaid Services regularly provide updates of areas designated as having health care provider shortages and communities that are considered rural.22 Opening a clinic in either of these settings places the NP in a publicly reported location of need. Along with determining the geographic need, assessing the specific needs of the patient population is imperative. For example, some rural populations do not have access to care within a 50-mile radius of their community. The geographic need would be for an NP-run clinic in closer proximity to the community. Other populations might have several internal medicine practices, but may lack a clinic to
ESTABLISHING AN APN CLINIC IN THE CANCER SETTING
care for the pediatric population. Some clinics prefer to focus care on preventive services, while other clinics focus on the acute care of patients and/or refer back to a primary care provider for continuing care. Dependent upon the population, the NP-run clinic should weigh the pros and cons of having a specialized NP in the clinic. The number of clientele needing specialty services must, at a minimum, be equivalent to the cost of employing the specialized NP. Table 1 provides the average salaries for NP specialties.23-27 The needs of the population must be met in order for the NP clinic to be successful. A needs assessment must consider the services currently available in the area and the distance to the nearest services most frequently needed by the population. Once a list of selected services is created, one must take into account the feasibility of meeting these demands. Next, rank the services and supplies needed by priority, with the greatest need ranked highest. For example, stocking the lab with blood draw equipment may take priority over x-ray equipment when forming a primary care clinic. As the clinic opens and has monetary funds coming in, higher-cost expenditures can take place. Credentialing and reimbursement are not guaranteed with insurance companies at the opening of the clinic; therefore, focus should be placed on the clinic’s immediate needs. Formation of the NP-run clinic is a multiple step process (Table 2). It is necessary to take financial considerations into account when deciding whether a clinic will be for-profit or non-profit. The clinic will require a monetary base to properly establish the foundational needs, such as medical equipment and office supplies. Non-profit clinics often use grant funds. Grant funding may specify exactly what is expected of the clinic, including location and every service provided. For-profit
TABLE 1. Average Salaries for Nurse Practitioner (NP) Specialties Specialty 23,27
Family NP Gerontology NP24 Pediatric NP26 Psychiatric NP24,25,27 Orthopedic NP25 Pediatric Endocrinology NP25 Cardiology NP24 Oncology NP24
Average Salary $83,984 $94,485 $82,101 $88,000 – $92,396 $70,000 – $90,000 $70,000 – $90,000 $90,370 $90,862
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TABLE 2. Formation of an NP Clinic Steps to Take
Tips on Decision Making
Determine the type of venture
Establish a business entity
Select a location for the practice
Obtain licenses and insurance
Decide whether this will be an individually owned business or a partnership, this will help in deciding what type of business entity to form Consult with an accountant and attorney to determine which type of legal entity to form (such as LLC, S Corporation, or C Corporation) After researching the needs of the community, seek out office space that will meet the business needs of the practice Business licenses – city, county, state Lab license - Clinic Laboratory Improvement Amendments (CLIA) license or waiver, depending on the extent of lab testing to be performed in the clinic Physician and NP Collaborative Agreements – dependent upon State of practice Insurances – coverage for the NP malpractice insurance, along with the other employees in the clinic
clinics have more liberty to decide what services may or may not be offered within the clinic. Next, determine the type of venture in which the business will function, such as a sole proprietorship or a corporation. Once the type of business has been selected, a Certificate of Formation will need to be filed with the state to record the business as a legal entity. At this point, the clinic lease can be secured in the business name. The municipalities in which the practice is located will require licensing. Insurance to cover the property and provider will also need to be acquired. Simultaneously, the NP and physician should establish their Collaborative Agreement required by the state; thus, allowing for the credentialing application process to begin.
NP REGULATIONS In the US, NPs must practice within their scope of certification and regulation. For a registered
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nurse (RN) to obtain an NP license the RN must first complete the necessary degree requirements and pass an examination from a national certifying body. Currently, there are two national certifying bodies, the American Nurses Credentialing Center (ANCC) and American Academy of Nurse Practitioners (AANP). The RN will take the examination that is specific to the NPs degree program of study. NPs are also governed on a state-by-state basis.28 From a business perspective, the business licenses required for an NP-run clinic are regulated by the city, county, and state. Dependent on the location of the clinic, some municipalities only require a license for the business, not the NP. It is imperative to review the legal requirements for licensing based on the physical location of the clinic. Along with the business license, it is important for NPs to keep professional licenses up-todate with the state nursing board. The NP must also maintain national certification with either ANCC or AANP. Each state has a Nurse Practice Act that sets forth the rules for licensure, education, scope of practice, and rules for disciplinary action.29 At this time, there are 20 states that allow NPs to practice in a full scope of practice.28 This type of practice allows NPs to practice independently of physicians. A limited scope of practice requires the NP to practice in collaboration with a physician under a set of specified guidelines based on regulations set by the NPs’ state board of nursing and/or the state medical board. There are currently 19 states that practice under this limited scope.28 The remainder of US states allow NPs to practice under a restricted scope, which prevents any independent practice by the NP (see Table 3).28 There may be additional certifications required for the NP to treat patients to the fullest scope of practice. For example, in Alabama, NPs that desire the legal ability to write prescriptions for controlled substances must apply for a Qualified Alabama Controlled Substances Certificate (QACSC).30 After approval of the QACSC, the NP may then apply for a Drug Enforcement Administration license that allows for an NP to prescribe controlled substances based on the legal limits of the State of Alabama.30 The NP may also seek advanced certification to further the knowledge base, such as nurse executive or nursing professional development.31,32
TABLE 3. State NP Scope of Practice
Full Practice Alaska Arizona Colorado Connecticut District of Columbia Hawaii Idaho Iowa Maine Minnesota Montana Nebraska Nevada New Hampshire New Mexico North Dakota Oregon Rhode Island Vermont Washington Wyoming
Reduced Practice
Restricted Practice
Alabama Arkansas Delaware Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi New Jersey New York Ohio Pennsylvania South Dakota Utah West Virginia Wisconsin
California Florida Georgia Massachusetts Michigan Missouri North Carolina Oklahoma South Carolina Tennessee Texas Virginia
NEGOTIATING THE ROLE OF THE PHYSICIAN The role of the physician in an NP clinic must be determined based on the needs of the clinic, the desires of the physician, and each state’s specific NP Scope of Practice. The role of the physician varies dependent upon how involved the physician would like to be in the clinic. Three NP clinics were asked about the roles the collaborating physicians have in their practices. The first clinic is a primary care clinic run with one NP and two office personnel to assist. The NP pays her collaborating physician a flat fee of $5.00 per patient visit each month. The physician is present 1 day a week for 8 hours. He reviews the designated number of patient charts set by the Board of Nursing collaborative requirements, consults with the NP on complex patients, and otherwise is not involved in direct patient care. The second clinic has a physician that prefers no involvement in patient care. The physician reviews the minimal required number of patient charts and is paid a flat monthly fee regardless of the number of patients seen by the NP. The third clinic also has a physician whom chooses no patient involvement.
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The physician goes to the clinic 1 day a week for chart review and consultation with the NP. This clinic has an agreement with the physician to pay him $5.00 per patient visit or $1,500 per month, whichever is the lessor of the two. As illustrated, there are numerous ways to establish the role and payment of a physician in an NP-run clinic. A first step is to determine the involvement of the physician with the clinic. Some physicians desire to be involved and want to provide patient care, while other physicians may choose to have no direct contact. When negotiating the fee for the physician, take into account the time commitment required of the physician, expertise, and if the physician is providing patient care. There should be a legal contract between the NP and physician that identifies the expectations of both parties to ensure that all involved are in agreement and working toward the same goal of quality patient care.
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agreement with the NP of what rate the NP will be reimbursed for services provided. Because NPs are caring for patients in a primary care setting to the fullest scope of practice, the same payment for services does not translate from the insurers to the NPs. Medicare currently reimburses qualified, credentialed NPs at a rate of 85% of what physicians would be reimbursed for the same services.33 Naylor and Kurtzman34 noted that NPs are often reimbursed 75% to 85% in comparison to the 100% physician reimbursement rate. The reduced rate of payment seems nominal until the NP notices that some private insurers have an extremely low reimbursement rate for NPs at a mere 55%. The credentialing process and reimbursement should be thoroughly researched when forming an NP-run clinic and financial decisions should be based on what population and services will be provided in the clinic.
REIMBURSEMENT CONSIDERATIONS
ADVANCED PRACTICE NURSING IN THE MEDICAL ONCOLOGY PRACTICE
It is necessary to begin the billing (credentialing) process before an NP-run clinic has opened the clinic. Credentialing is the process of verifying that a professional has the education and licensure that is claimed on a professional’s curriculum vitae and that the same professional can legally carry out the practices billed to health insurance companies for reimbursement.32 Some medical insurance companies have a rigorous credentialing process for medical providers that can take up to 120 days to complete. One nationally known insurance carrier requires not only the NP to become credentialed, but also requires the NP’s collaborating physician to be credentialed with the insurer. The task of completing credentialing has often been compared with the same amount of paperwork required to obtain a house mortgage. While the mountain of paperwork may seem daunting, this is a task that must be completed to receive reimbursement for medical services rendered to patients. One might also research all the major medical insurance companies to determine which insurance companies will allow for direct billing by NPs. Even with the recognition of NPs nationally, numerous insurance companies do not allow for credentialing of NPs and will not pay the professional for medical services provided. As credentialing comes to completion, the individual insurance companies will often solicit an
Although NPs are practicing in various oncology settings, most NPs are employed in the outpatient clinic with approximately 80% of patients undergoing treatment in the ambulatory setting.35 Previous research has documented clinical productivity for oncologists working with PAs and NPs, including increased efficiency and physician satisfaction, improving overall care, and increasing physician time for complex cases and research.6 Little is known, however, regarding practice productivity and efficient practice models as a result of differing utilization of NPs in oncology and the variance in state scope-of-practice laws that determine NP services and the extent of independent practice. Buswell et al36 evaluated productivity, revenue, and provider and patient satisfaction utilizing three practice models in an oncology ambulatory practice. The three practice models included: the independent visit model, defined as physicians, NPs, and PAs functioning independently for two thirds or more of their patients; the shared visit model, defined as physicians, NPs, and PAs seeing two thirds of their patients together; and the mixed visit model, defined as physicians and midlevels seeing patients together and independently. Results indicated that overall productivity and visit fees were similar in the three models and provider and patient satisfaction were high in all models. Further research is
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needed to evaluate quality of care, patient and provider satisfaction, productivity, and cost, ultimately defining an efficient care model for physicians, NPs, and PAs in the oncology setting.
CONCLUSION With the aging population and increased incidence in cancer, the increasing numbers of cancer survivors, the aging of the health care workforce,
and the projected shortage of oncologists, NPs can play a key role in caring for patients with cancer. The NP has many opportunities and role functions, both traditional and innovative, in the cancer clinical setting and can contribute to the cancer care team’s delivery of quality oncology care. These opportunities can be embraced by NPs taking the steps to establish NP-run clinics. The clinics can then fulfill the needs of the patient population and provide a high-quality standard of care that will better the patients’ health.
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