More and more rheumatologists are looking to expand their practices by adding a nurse practitioner (NP) or physician assistant (PA) to help with increasing patient loads. While an additional person can certainly enhance practice operations, it can be difficult to find an ancillary health professional trained in rheumatology, and daunting for a small practice to consider training an NP or PA in the subspecialty. On the other hand, a skilled NP or PA can benefit the practice overall and help provide better care for patients—in the initial evaluation of a patient, patient education, and routine patient follow-up that may include joint injections and other procedures. With the advent of a new online rheumatology training program for NPs and PAs that will launch at the ACR/ARHP Annual Scientific Meeting this month, that skilled health professional just might be easier to find.
Explore This IssueOctober 2008
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“This training program will be a pivotal source for anyone who wants to build or improve their knowledge and skills in the care of patients with rheumatologic disease,” says Basia Belza, PhD, RN, scientific editor of the ACR/ARHP Nurse Practitioner and Physician Assistant Postgraduate Rheumatology Training Program and a professor in the School of Nursing at the University of Washington in Seattle. Although the training program was designed for nurse practitioners and physician assistants who are new to the field, others will be able to register and benefit from it, too. The program provides basic and advanced rheumatology-practice knowledge and clinical skills. It is delivered online. The Web site has a user-friendly interface and consists of 19 modules, says Dr. Belza. There are three sets of modules—core, adult, and pediatric—each authored by experts in the field and reviewed by external reviewers. Prospective students can register for one of the three options: core and adult modules; core and pediatric modules; or core, adult, and pediatric modules.
The training program is an outgrowth of discussion within the ACR and ARHP over the past eight years about the shortage of rheumatologists and long-term estimates that the demand for rheumatologic care will continue to grow, while the supply of trained rheumatologists will not keep pace. “The impact of the shortage was being noticed more and more and we felt that we had to take action to help rheumatologists in their daily practice,” says Karen Kerr, MSN, NP, CPNP, PNP-BC, a rheumatology nurse practitioner at Children’s Hospital of Michigan in Detroit and the immediate past president of the ARHP. Kerr assisted the ACR Workforce Study Group with information about how advanced practice clinicians, such as NPs and PAs, assist in practice settings around the country. The group published its workforce report in 2007. “We know from experience that adding an NP or PA to the rheumatology staff can easily double the number of patients that can be seen,” says Kerr. “This is a good practice model for chronic illness, and particularly for rheumatology. It is a benefit to both adult and pediatric patients.”
According to the ACR workforce study published last year, 97% of all rheumatology practices say they accept new patients, but the mean wait time to get a non-urgent appointment is more than a month (37 days). The study found that 15.5% of rheumatology practices employ an NP and another 7.2% employ a PA, while 10% said they were actively seeking to hire an NP or PA. Another 25% of the practices reported a desire to hire a PA or NP within five years. The new NP and PA training program is a direct response to the Workforce Study’s urgent call for practice re-design as a way to preserve and improve the quality of the profession. Additionally, surveys from health professionals indicated a preference for online educational programs that would not involve costs associated with travel.
NPs and PAs in the Practice Setting
Practice redesign is nothing new to Paul Caldron, DO, head of the Arizona Arthritis and Rheumatology Associates in Paradise Valley, Ariz., and a member of the Workforce Study Advisory Group. Caldron has employed an NP for close to 20 years. His practice overall includes nine rheumatologists and nine NPs or PAs. “Our experience with this model is incredibly good,” says Dr. Caldron.
Although state laws differ on how NPs and PAs can practice, and individual rheumatologists may have different models, Dr. Caldron’s practice provides a window into how it can work. “We see six new patients a day on average,” he explains. The nurse practitioner or physician assistant sees the new patient, does a history and physical, and then presents that information to me before I see the patient. We discuss what needs to be done, the NP or PA takes notes and implements the plan of care while I go on to my next patient,” says Dr. Caldron. “I generally see the patient on the second visit, and once a stable course of treatment is set we alternate seeing the patient at each visit. If there is no change, there is no need for me to see the patient.” Dr. Caldron describes the addition of a NP or a PA to the practice as, “having a senior fellow that never goes away.”
Some rheumatologists are reluctant to turn over even some care of their patients (particularly a new patient) to someone who is not a physician, says Rod Hooker, PhD, PA, head of rheumatology research at the Department of Veterans Affairs (VA) in Dallas, Texas. He hears these sentiments within the VA, the largest employer of NPs and PAs in the country. “We have only four PAs doing rheumatology in the entire VA system.” Hooker hopes to see penetration of these practitioners into rheumatology just as it is in other medical specialties. He encourages individual practices to determine the best role of the NP or PA in the rheumatology practice. “There is so much routine care that can be shifted to the NP or PA,” he says. “This allows the rheumatologist to spend more time with patients with more complex needs.” Dr. Hooker also served as a member of the ACR Workforce Study Advisory Group.
“The management of chronic disease is well suited to the skills and training of the nurse practitioner or physician assistant,” adds Dr. Hooker. Kerr agrees. “You can have a long-term relationship with the patient and really see that what you are offering is making a difference,” she says. “Getting the disease to go into remission is a very rewarding experience for the NP or PA.”
Dr. Belza notes that the NP/PA program has several novel components. Each of the learning modules starts with a pretest or a pre-assessment of the person’s own knowledge about rheumatology. “We use case studies in this component with experts in the field responding to the challenges presented in the case,” she explains. The clinician taking the program then listens to the central portion of the program—an audio-annotated presentation of PowerPoint slides on the topic of that module. There are 18 hours of annotated lectures and more than 2,800 slides that made up the 19 modules. Each of the annotations varies in length from 30 to 120 minutes.
Clinical tip sheets are referred to as “pearls” and can be printed out for clinical or practice setting use. The course also includes current references and a post-test to test knowledge learned in each module. The individual has three chances to complete each registered module posttest with a 70% score or greater, which is necessary to successfully complete the module and receive a certificate of completion for their registered module track. “The individual can spend as much time as they prefer on a given module and can complete each module in increments of time based on their personal schedule,” adds Dr. Belza.
“I think many of my fellow NPs and PAs will find a career in rheumatology as rewarding and exciting,” says Kerr. “It also allows us the opportunity to do clinical research,” she adds.
“Rheumatology is a great opportunity for the nurse practitioner,” says Tiffany Fotinos, RN, FNP-C, the NP who works with Dr. Caldron. “I like the diversity of being able to do patient care and research.”
For more information on the training program go to http://rheumatology.org/arhp.
Terry Hartnett is a frequent contributor to The Rheumatologist.