Neurology advanced practice providers

RECOMMENDATIONS FOR BEST PRACTICES

The ultimate goal of integration of nonphysician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. APPs can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision. They can provide many aspects of care that neurologists currently perform, such as education of patients and families, counseling, resource management, and follow-up care.⁸ Therefore, APPs have the potential to improve outcomes at a lower cost to patients and to the system by improving outpatient access, potentially reducing the need for emergency care. In addition, APPs may be able to assist in patient education, which may also decrease the overuse of the medical system. Incorporating APPs into neurologic practice to assume such responsibilities may alleviate some of the stress and burden associated with the care of chronically ill neurology patients, thereby reducing the recently reported high “burn out” rate of neurologists.⁹

There is no definitive way to use APPs in multidisciplinary teams. The model varies depending on the size and specialty focus of the neurology practice and is further determined by individual state laws. It is crucial for the physician(s) to have a desire to participate in a collaborative practice. To create a cohesive group, a defined mission with clear vision and values must be stated. The team should acknowledge each provider's strengths and limitations. It is necessary to recognize the accepted scope(s) of practice and allow each member of the team to practice to the full extent of his or her professional license, training, and abilities.

Neurology is a highly nuanced field of medicine. Advances in medicine occur at a rapid pace.¹⁰ Providers are required to refine their skills continuously. It is with this understanding that the American Academy of Neurology (AAN) recommends that within neurology-specific practices, the clinical leader of a multidisciplinary team be a board-certified neurologist. Operationally, high-functioning teams are generally led by consensus, allowing all team members to maximize their skill set.

While integrating APPs offers many advantages, there are barriers, including the following:

• The cost of onboarding APPs to neurologic practice before any financial relief is realized, since many APPs come out of formal training with little or no neurology experience.

• The retention of well-trained neurology APPs. It is hoped that the AAN's current efforts can improve retention of APPs in neurologic practice and provide educational resources in neurology to ensure a stable and skilled workforce for our members.

• The challenge of transition to team-based care in neurologic practice. This challenge exists for all members of the team who may need to redefine their roles in a multidisciplinary care structure. This is a particular concern in academic centers due to the potential for diluting the clinical experience for residents and fellows (further complicated by duty hour restrictions). These concerns will need to be addressed both nationally and institutionally.

Because the AAN recognizes that APPs are an integral part of multidisciplinary neurology teams, the AAN, through the efforts of the APP Work Group, will develop resources to educate its members on the following:

• Creating business models (in various settings) that support a multidisciplinary approach

• Billing/coding for multidisciplinary teams

• Integrating additional clinicians/providers into neurologic practice

• Establishing the link between employment of an APP and improved value and outcomes by encouraging study of the value proposition

• Linking the integration of APPs into neurology practice with improved lifestyle and reduced burnout

The AAN needs to gain a better understanding of what APPs desire from the AAN and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to do the following:

• Accurately identify what membership benefits are valuable to APPs

• Accurately identify what educational gaps can be filled by our programs

• Address and advertise the recertification and maintenance of certification requirements for APPs that can be met by AAN offerings

• Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value-based care

• Develop a Fellow of the AAN status for APPs that is similar in requirements to the Fellow statuses for physicians and research scientists

• Develop an APP consortium within the AAN to foster growth and leadership for this section of our membership

To date, the AAN has created a new member category specifically for APPs with 2 affordable levels. In addition, a course oriented specifically to the professional needs of APPs was offered at the 2015 Annual Meeting, as well as APP-specific networking and professional events.

Integration of neurology APPs into AAN membership and initiatives is a major priority for the organization, prompting the formation of a Work Group to pursue these issues further. The purpose of this AAN Work Group is to do the following:

• Implement recommendations from APPs to enhance professional and educational offerings from the AAN to appeal to a wide range of neurologic providers

• Identify the pitfalls to avoid and best practices to follow when joining, establishing, or adding to a multidisciplinary team, and

• Advocate for study of the effect of APP integration on the quality and cost of neurologic care.

In addition to AAN staff, the Work Group is composed of neurologists, a practice administrator, NPs or APNs, PAs, and CNSs, all representing varied geographic locations and clinical roles. Our efforts are informed by a survey administered in 2014 by the AAN to neurologists, practice administrators, and APPs. It is anticipated that the evolution of multidisciplinary care teams may extend to other providers (physical and occupational therapy, speech therapy, social work, pharmacy; nutritionists, neuropsychologists, etc.) in the future, providing this Work Group with ongoing responsibilities regarding integration into the AAN.