VA Supports APRN Independent Practice
In May 2016, the U.S. Department of Veterans Affairs (VA) issued a proposal to allow APRNs the ability to practice to the full extent of their licensure in VA facilities. See the full article for more information.
During a session presented at the 2016 ASCO Annual Meeting that discussed team-based oncology care, ONS member Wendy H. Vogel, MSN, FNP, AOCNP®, an oncology nurse practitioner at Wellmont Cancer Institute in Kingsport, TN, discussed how advanced practice providers can be involved in the care team process.
The oncology landscape is growing increasingly complex, and cancer incidence is expected to increase without an associated increase in the number of oncologists. Practices will need to be more collaborative to meet the demands of care. The ASCO Workforce Advisory Group recommends increasing the use of advanced practitioners (APs) to improve practice efficiency.
Estimates suggest that 11,000 APs are working in oncology. The legal scope of AP practice may vary from state to state due to the type of AP, experience, and facility. Most APs have prescriptive privileges, with different requirement rules for controlled substances.
Roles and function of the AP in oncology can include
- Ordering, interpretation, and discussion of diagnostic tests
- Cancer risk assessment, screening, and management
- Inpatient hospital rounds
- Patient education
- Survivorship and palliative care
- Research
- Patient navigation
- Case management.
Vogel discussed three care models in oncology.
- Incident-to model: The AP sees the patient independently while following the physician’s plan of care. The physician can consult if needed and is generally in the office suite. The billing must be regulated by the Centers for Medicare and Medicaid Services for “incident-to” at the full physician fee schedule.
- Shared visit model: Both the AP and physician see the patient, with the physician completing visit notes and billing for services.
- Independent visit model: The AP sees the patient independently while following the physician’s plan of care. The physician can consult if needed, usually for critical treatment decisions only. Billing is done under the AP’s own provider number at 85% of the physician fee schedule.
When choosing an integrated care model, Vogel suggested giving consideration to the practice needs and patient volume, while considering the training, skills, and expert knowledge of both physicians and APs.
Researchers published a study in the Journal of Oncology Practice where they found that practices where APs work with all practice oncologists typically demonstrate higher productivity compared with APs working with one oncologist exclusively.
Vogel discussed barriers to including APs in oncology care teams, such as AP nurse autonomy restrictions and insufficient support, mentoring, and training in oncology. In terms of training, most APs are trained as generalists rather than oncology specific, and it could take one to two years for APs to become fully competent in the oncology space. Vogel noted that unfortunately, the most common training is informal and on-the-job.
Integrating the AP into the team takes time and deliberate planning and requires shared goals, such as improving patient outcomes, increasing practice productivity, and improving timely patient access to care. Each team member’s unique strengths, skills, and interests should be encouraged.
“As oncology care becomes increasingly complex and shortages of oncologists increase, collaborative care is essential to meet these demands,” Vogel concluded. “The oncology AP is a cost-effective [and] integral part of the professional oncology team and can also increase practice productivity and efficiency.”