ThisworkisfundedthroughHRSACooperativeAgreementU81HP26495‐01‐00:HealthWorkforceResearchCentersProgram.

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHillhttp://www.healthworkforce.unc.edu

PhysicianAssistantandNursePractitionerRolesinPatient‐CenteredMedicalHomes

ChristineM.Everett,PhD,MPH,PA‐C;BrandiLeach,MS;PerriMorgan,PhD,PA‐C ResearchBrief,February2015

I.ExecutiveSummary/KeyFindings

Team‐basedcareinvolvingphysicianassistants(PAs)andnursepractitioners(NPs)isonerecommendedstrategyforimprovingaccessandqualityandreducingcostinthepatient‐centeredmedicalhome(PCMH).PAsandNPscan,anddo,performavarietyofrolesonprimarycareteams.ThissuggeststhatthereisplasticitywithintheprofessionsandbetweenPAs,NPs,andphysicians.

PrimarycarePAandNPclinicalrolescanbedefinedbytheapproachtocaredistributionbetweenPAorNPandthecollaboratingphysician.WhenPAsandNPsprovidethemajorityofprimarycareandperformallofthefunctionsofprimarycareforagroupofpatientsinamannersimilartophysicians,theyareactingasaprimaryproviderofcare.WhenPAsandNPsprovideonlyasubsetofthefunctionsofprimarycare,suchasprovidingsame‐dayacutecarevisitsonly,theyareactingasasupplementalprovider.

WhilesomestudieshavedescribedPAandNProleswithinagivenPCMH,itisuncleartheextenttowhichdifferentPAandNProlesarebeingimplementedinPCMHsnation‐wide.ThisprojectaimstodescribePAandNProlescurrentlyimplementedinprimarycarepracticesparticipatinginpublicand/orcommercialPCMHprograms,andtoassessprimarycarePAandNPperceptionsofrolechangesduetoPCMHimplementation.

CONCLUSIONSANDIMPLICATIONSFORPOLICY

1) ThefindingthatPAsandNPsperformdifferentpatternsofclinicaltasksinprimaryversussupplementalproviderrolesmaybeusefulforworkforcemodelingofthetasksubstitutionpotentialofPAsandNPs.

2) PCMHPAandNProlesseemtobewellsuitedtocurrenttraining,butsincePAsandNPsreportnotmaximallyusingtheirtrainingupto30%ofthetime,teammodificationsandtrainingthatpromotetaskdelegationbyPAsandNPstostaffwithlesstrainingmightincreaseefficiencyofcare.

3) FewPAsandNPsreportperformingtasksforwhichtheyareunderqualified,butsincethesesituationsarepotentiallydangerous,provisionsforback‐upshouldbeavailabletothesePAsandNPs.

4) FewPAsandNPsarespendingsignificanttimeperformingsomenewerPCMHfunctionssuchaspopulationhealthmanagementandqualityimprovement.Increasedtrainingintheseareasmayimprovethelikelihoodofperformingsomeofthesefunctions.

5) AdditionalinvestigationiswarrantedtofindpotentialcausesandsolutionstothedissatisfactionreportedbythePAsandNPswhodidexperiencerolechangesassociatedwithPCMHimplementation.

 

2  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

WithsupportfromtheNationalCenterforHealthWorkforceAnalysisandtheCarolinaHealthWorkforceResearchCenter,housedattheCecilG.ShepsCenterforHealthServicesResearch(ShepsCenter)attheUniversityofNorthCarolinaatChapelHill,weconductedacross‐sectionalsurveyin2015ofasampleofPAsandNPsemployedinpracticesparticipatinginpublicorcommercialPCMHprogramsin5states.ResultsshowthatalargemajorityofPAsandNPsinPCMHsreportpracticinginprimaryproviderroles,withasmallminorityreportingpracticeinsupplementalrolesonly.MostPAsandNPsreportthattheirrolesarewell‐definedandmatchedtotheirleveloftraining.Whenworkdidnotmatchtheirtraining,itwasmuchmorefrequentlyworkthatcouldbedonebysomeonewithlessratherthanmoretraining.PAsandNPsworkinginprimaryproviderrolesreportdifferentclinicaltaskdistributionsthanthosewhoworkinsupplementalroles.Forexample,whenactinginsupplementalroles,PAsandNPsreportmorefrequentlyprovidingacutecare,butlessfrequentlyprovidingchronicillnessandpreventivecarethenwhenactinginprimaryproviderroles.TimespentonnewertasksassociatedwithPCMHstatusvarieswidely.CarecoordinationandmanagementareperformedbymanyPAsandNPsforatleastafewhoursweekly,butpopulationhealthandqualityimprovementarelesscommonlyreported.PCMHimplementationdoesnotappeartohaveresultedinclinicalrolechangesformanyPAsorNPs.However,whenrolechangesdidoccur,theysometimesresultedinPAorNPdissatisfaction.UnderstandinghowprimarycarePAandNProlesareaffectedbyPCMHimplementationisessentialforaccurateworkforcemodeling,training,andpolicy.DevelopinganunderstandingofPAandNPtasksandrolesinthePCMHmodelcancontributetomodelingtheplasticityoftheprimarycareworkforce.DeterminingifPAandNProleschangewithPCMHimplementation,ifnewtasksareperformed,andthechallengesassociatedwithrolechanges(e.g.,adequacyoftrainingfornewrolesandtasks)caninformeducationandtrainingprogramsfortheseprofessions.TheresultsofthisprojectcanalsoassistorganizationstransformingtoPCMHswithprimarycareteamredesign,helpstatepolicymakerswithissuesrelatedtoscopeofpractice,andinformfederalpolicymakerswithworkforceplanningandfinancingofhealthcaredelivery.

 

 

 

3  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

II.BackgroundTheimplementationofteam‐basedcareisconsideredessentialtoaddressingthefragmentedandinefficientUShealthcaresystem.1Team‐basedcareinvolvingphysicianassistants(PAs)andnursepractitioners(NPs)isonerecommendedstrategyforimprovingaccess,quality,andcostofcareinthepatient‐centeredmedicalhome(PCMH).2PAsandNPscan,anddo,performavarietyofrolesonprimarycareteams.3PrimarycarePAandNPclinicalrolescanbedefinedbytheapproachtocaredistributionbetweencliniciansontheteam,includingPAs,NPs,andphysicians.Historically,theroleofPA/NPshasbeenclassifiedintotwocategoriesreflectingthelevelofPAandNPinvolvementandthedivisionofresponsibilitiesbetweenthePAorNPandthecollaboratingphysician:primaryproviderofcareandsupplementalproviderofcare.4‐6WhenPAsandNPsprovidethemajorityofprimarycareandperformallofthefunctionsofprimarycareforagroupofpatientsinamannersimilartophysicians,theyareactingasaprimaryproviderofcare.WhenPA/NPsprovideonlyasubsetofthefunctionsofprimarycare,suchasprovidingsame‐dayacutecarevisitsonly,theyareactingasasupplementalprovider.Theseroleseithersupplement,orsubstituteforphysicianstovaryingdegreesandareassociatedwithdifferentpatternsofoutcomes.3,7Thissuggeststhereisplasticity,orthecapacitytoshiftprimarycaretasks,withintheprofessionsandbetweenPAs,NPsandphysicians.8WhilesomestudieshavedescribedPAandNProleswithinagivenPCMH,itisuncleartheextenttowhicheachpotentialroleisbeingimplementedinPCMHsnation‐wide.3,9

SincePCMHsemphasizeaccessandqualityofcare,newfunctionssuchaspopulationhealthmanagementandcarecoordinationmayaltertherolesofPAsandNPsonprimarycareteams.ToparticipateinpublicandcommercialPCMHprograms,practicesmustmeetcertainstandards,includingenhancedaccess,carecoordinationandperformanceimprovement.10Meetingthesestandardscanexpandtaskssuchascaremanagement(e.g.,patienteducationandcoaching),carecoordination,populationhealth,andqualityimprovement.Addingthesenewfunctionsmaysignificantlyshifttasksbetweenteammembers,resultinginnewordifferentrolesforPAsandNPs.11‐13

UnderstandinghowprimarycarePAandNProlesareaffectedbyPCMHimplementationisessentialforaccurateworkforcemodeling,training,andpolicy.DevelopinganunderstandingofPAandNPtasksandrolesinthePCMHmodelcancontributetomodelingtheplasticityoftheprimarycareworkforce.DeterminingifPAandNProleschangewithPCMHimplementation,ifnewtasksareperformed,andthechallengesassociatedwithrolechanges(e.g.,adequacyoftrainingfornewrolesandtasks)caninformeducationandtrainingprogramsfortheseprofessions.TheresultsofthisprojectcanalsoassistorganizationstransformingtoPCMHswithprimarycareteamredesign,helpstatepolicymakerswithissuesrelatedtoscopeofpractice,andinformfederalpolicymakerswithworkforceplanningandfinancingofhealthcaredelivery.

Thisresearchbrief:1)describesPAandNProlescurrentlyimplementedinprimarycarepracticesparticipatinginpublicandcommercialPCMHprogramsin5states;and2)assessesprimarycarePAandNPperceptionsofrolechangesduetoPCMHimplementation.

 

 

4  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

III.MethodsSampleUsingthefollowingsamplingscheme,weultimatelyselected5statestoserveasourprimarysamplingframe:first,weexcludedstatesthatarelistedbythePatient‐CenteredPrimaryCareCollaborative(PCPCC)ashavingnon‐significantPCMHactivity.Fromtheremainingstates,weselectedstatesineachCensusregion(West,South,Midwest,Northeast).OuraimwastoproduceafinalsamplethatexpressedvariationinstatelegislationandregulationrelatedtoPCMHsaswellasvariationintheexistenceofPCMHdemonstrationprograms,populationcharacteristics,Medicaidspendingandexpansion,andhealthprofessionalworkforcesupply.The14statesmeetingthesecriteriawere:Arkansas,California,Idaho,Kentucky,Maine,Michigan,Minnesota,NorthCarolina,Nebraska,NewJersey,Nevada,Oregon,Pennsylvania,andTexas(SeeAppendixfordetails).ThefivestatesselectedforthisstudywereMaine,Michigan,Arkansas,Idaho,andOregon.

Asurveywaspilotedthenmailedto1,450PAsandNPsworkinginprimarycarepracticesparticipatinginpublicorcommercialPCMHprogramsintheselectedstates.PAsandNPswereidentifiedbytheresearchteamusingthePatient‐CenteredPrimaryCareCollaboratewebsite(https://www.pcpcc.org).ThisisapublicallyavailableresourcethatlistspublicandcommercialPCMHprogramsineachstate.ProviderinformationwasfoundeitheronthePCMHprogramwebsite,orobtainedfromtheclinicwebsite.Theresponseratetothesurveywas15.9%(N=230).

SurveyToolRespondentsweregiventheoptiontocompletetheanonymoussurveyinpaperorelectronicformat.Initialandfollow‐upsurveysweresenttoallPAsandNPsinthesampleinanattempttoimproveresponserates.Thesurveyinstrumentcontainedamixofcategoricalandopen‐endedquestions.QuestionsassessingPAandNPclinicalroleswerebasedonapreviouslydevelopedconceptualizationofprimarycarePAandNProles,whichpositsthatclinicalrolesaredefinedbythelevelofinvolvement(primarycarevs.supplementalprovider),typesofservicesprovided(chronicdiseasecare,acutecare,preventivecare,etc.),andthecomplexityofpatientsserved.7

AdditionalsurveyitemsassessedtheperformanceofnewtasksassociatedwithPCMHdesignation,suchaspopulationhealthmanagement,caremanagement,carecoordination,andperformanceimprovement.Thepresenceofarolechangewasassessedwithasinglebinaryquestion.QualitativeandquantitativefeaturesofPAandNProlechange(typeandmagnitude)andchallengesassociatedwiththoserolechanges,suchasadequacyoftraining,wereassessedwithcategoricalandopen‐endedquestions.InformationoneachPAorNPwasalsocollected,includingprofession,gender,levelandtypeoftraining,yearsofexperience,yearswiththepractice,andpanelsize.Itemsalsoassessedcliniccharacteristics,suchasgeographiclocation,specialtyoftheclinic,clinicsize,anddescriptionsofthepatientpopulation.

AnalysisDescriptivestatisticsincludingmeansandpercentageswerecalculatedtodescribeclinicandPAandNPcharacteristicsandcurrentPAandNProles.Roleandtaskchangesinvolvedmultipleanalyses.Forcategoricalandbinaryvariables,suchastheindicatorvariableforrolechange,descriptivestatisticssuchasmeansandpercentageswerecalculated.Responsestoopen‐ended

 

5  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

questionsassessingPAandNPperceptionsofroleandtaskchangeswerequalitativelyanalyzedtoidentifythemesinresponses.14

IV.ResultsTherespondentswere82%femalewith61%reportingtheirprofessionasNPand38%reportingtobePAs.ThemajorityoftherespondentsreportedtheywereMaster’s‐trainedwithameanof11yearssincegraduation,butameantimeoflessthan3yearswiththeircurrentclinic.(Table1).ThemajorityofrespondentsreportedpracticinginFamilyMedicineclinics(71%)orinsmalltowns(51%).Thirty‐eightpercent(38%)reportedworkinginaprivatepracticeand40%reportedworkingforahealthsystem.Mostreportedworkingwithtraditionalprimarycarepractitionerssuchasphysicians,otherPAsandNPs,andnursesbutawiderangeofhealthprofessionalswerelessfrequentlyrepresentedinthepractices.(Table2)Table 1. PA/NP Characteristics (N=217)

Respondent Characteristics Freq. % Mean Std. Dev. Min. Max. Gender

Female 186 82

Male 41 18 Profession Physician assistant 82 38 Nurse practitioner 132 61 Other 3 1 Average years at this clinic Less than 1 year 17 7 1-3 year 94 41 4-10 years 74 32 Greater than 10 years 43 19 Highest degree - Physician Assistants PhD 1 1 Master's degree 47 57 Other degree (includes PA-C) 34 41 Highest degree - Nurse Practitioners PhD 2 2 Clinical doctorate (DNP) 13 10 Master's degree 124 94 Other degree 4 3 Average years since graduation 11 9 1 40

Average number of hours worked per week 40 15 5 200

 

6  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

Table 2. Clinic Characteristics (N=203) Clinic Characteristics Frequency Percent State where clinic is located

Arkansas 23 10

Idaho 17 8

Maine 76 34

Michigan 39 17

Oregon 70 31

Location type

Rural 38 17

Small Town 113 51

Suburban 25 11

Urban 47 21

Clinic type

Private practice 78 38

Part of a hospital system or other health system 82 40

Community health center 35 17

Free clinic 0 0

School-based clinic 0 0

Other 8 4

Clinic Specialty

Family Medicine 151 70

General internal medicine 23 11

General pediatrics 18 8

General geriatrics 0 0

Other 23 11

Percent of clinics with at least one…

Physician 209 91

Medical assistant 198 86

Nurse practitioner 184 80

Nurse (excluding NPs) 177 77

Physician assistant 138 60

Social worker 92 40

Pharmacist 44 19

Health educator 41 18

Nutritionist 37 16

Other type of worker 37 16

Community health worker 32 14

Psychologist 28 12

Psychiatrists 25 11

Physical therapist 21 9

Dentist 18 8

Occupational therapist 5 2

Public health worker 2 1

 

7  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

PrimaryCarePAandNPRolesMorethan90%ofrespondentsreporttheirrolesarewelldefined.(Table3)Seventy‐threepercentreportactinginaprimarycareroleforanaveragepanelsizeof930patients(SD=770).Only27%ofrespondentsreportpracticinginapurelysupplementalrole.PAsandNPsreportbetweenone‐thirdandtwo‐thirdsoftheirpatientsaresocialormedicallycomplex.(Table4)Approximatelytwo‐thirdsofrespondentsreportthatgreaterthan75%oftheirworkiswellmatchedtotheirtraining.Similarly,81%reporttheydonothaveadequatetrainingforlessthan5%oftheworktheyperform,butmostalsoreportatleastasmallportionoftheirworkcouldbeperformedbysomeonewithlesstraining(44%report<5%oftasksand43%report6‐24%oftasks).(Table5)

Table 3. PA and NP Reported Clinical Roles (N=228)

PA & NP Role

Very clearly defined

Somewhat clearly defined

Neither clear nor

ambiguous Somewhat ambiguous

Very ambiguous

PCP only (N=3) 100 0 0 0 0

PCP and supplemental provider (N=163) 73 22 4 1 0

Supplemental provider only (N=62) 58 31 2 10 0

PCP=primary care provider

Table 4. Percent of patients that are medically or socially complex, by provider role type (PCP Role N=160; supplemental provider N=135)

PCP Role Patients Supplemental Role Patients

PA & NP Role % Medically

Complex % Socially Complex

% Medically Complex

% Socially Complex

PCP and supplemental provider 63% 56% 34% 33%

Supplemental provider only N/A N/A 51% 42%

Table 5. Perception of Amount of Work Matching Training (N=230)

Percentage of respondents saying X percentage of their work is:

<5% 6-24% 25-49% 50-74% >75%

Work that could be done by someone with less training 44 43 9 3 0

Work for which you do not have enough training 81 16 2 1 0

Work that is well-matched to your training 1 1 6 24 67

 

8  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

TasksPerformedinPrimary(PCP)versusSupplementalProviderRoles

AwiderangeofclinicaltasksareperformedbyPAsandNPsindifferentroles,butdifferentpatternsofservicedeliveryexistbyrole.Forty‐sevenpercent(47%)ofPAsandNPsreporttheyperformchronicillnesscareinmorethan50%oftheirvisitswhenactingasprimarycareproviders,butonly12%reportsimilarchronicillnesscarewhenactingassupplementalproviders.(Table6)Similarly,16%ofPAsandNPsinprimaryproviderrolesreporttheyprovidepreventivecareingreaterthan50%oftheirvisits,comparedto6%whenactingassupplementalproviders.Incontrast,8%ofPAsandNPsinprimaryproviderrolesreporttheyprovideacutecareingreaterthan50%oftheirvisits,comparedto37%whenactingassupplementalproviders.Manyrespondentsreportperformingcarecoordination(89%),caremanagement(79%),transitionalcare(73%)andqualityimprovement(53%)atleast1hourperweek.However,only35%reportperformingpopulationhealthmanagementtasks.(Table7)

Table 6. Percentage of PA/NPs Reporting Delivery of Primary Care Service Types by Role During Visit (in PCP role N=168; In supplemental provider role N=228)

Primary Care Service Type

In Role as Primary Care Provider In Role as Supplemental Provider 0% 1-25% 26-50% 51-75% >75% 0% 1-25% 26-50% 51-75% >75%

Acute care 2 52 38 6 2 8 30 25 20 17 Chronic Illness Care 2 19 34 34 11 17 55 16 9 3 Preventive care 4 45 35 14 2 27 48 19 5 1 Mental health care 2 55 26 14 4 21 59 12 5 2 Behavioral health care 10 48 25 11 6 32 53 9 5 2 Pregnancy 80 19 1 0 0 89 10 0 1 0 Post-hospital care 10 76 10 4 1 33 59 5 3 0 Other services 95 2 1 0 2 91 4 1 1 3

Table 7. Additional PCMH Tasks (N=225)

Percentage of respondents spending X hours p/week engaged in each task

0 hrs 1-5 hrs 6-10 hrs 11-15 hrs 16-20 hrs >20 hrs

Population health management 64.89 31.11 3.11 0 0 0.89 Quality improvement projects 44.39 52.91 2.24 0 0.45 0 Care coordination 10.67 71.11 11.11 2.22 0.89 4 Care management 20.63 64.57 6.73 2.24 2.24 3.59 Supervisory tasks 56.44 32.89 5.33 1.78 1.78 1.78 Transitional care 26.58 59.91 9.46 2.25 0.45 1.35 Teaching 24.32 31.53 24.32 8.11 4.95 6.76

 

9  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

RoleChangesRoleswitchingassociatedwithPCMHimplementationwasinfrequentlyreportedbyrespondentsandoccurredforavarietyofreasons.(Table8)Seventeenpercentofrespondents(n=39)reporttheirrolehaschangedsincePCMHimplementation.Forthosereportingarolechange,increasesinadministrativepaperworkandelectronicmedicalrecord(EMR)workweremostfrequentlyreported(38%).ReportsofincreasesinnewtasksrelatedtoPCMHimplementationwerealsocommon,includingcarecoordinationandtransitions(11%),populationhealthactivities(5%)andqualityimprovement(8%).Asmallernumberofrespondentsreportedstructuralchangesintheirrole.Somereportedtheyweremovedfromaprimaryproviderroletoasupplementalrole(8%),nowactedasamemberofateam(8%),orhadincreasedleadershiproles(5%).Oftheninerespondentswhovolunteeredtheirattitudetowardsthechanges,mostweredissatisfied(n=8).

Table 8. Role Changes: themes from responses to open-ended question about role change after PCMH implementation (N=39)

Provider role change after PCMH implementation Frequency Percent

Respondents who answered "yes" their role changed 39 17 Type of role change More paperwork/EMR entry 14 38 More care transition and coordination 4 11 Scheduling changes 4 11 Can't see as many patients 4 11 More quality improvement activities 3 8 No longer a PCP/switched to a support role 3 8 Work as part of a team 3 8 More/different meetings 2 5 Population health involvement 2 5 Develop more detailed care plans 3 More leadership 1 3 More stress 1 3 More standardized care 1 3 More involvement with patient's families 1 3 More access to services 1 3 Response to role change Dissatisfied 8 22 Satisfied 1 3

     

 

 

10  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

V.DiscussionThePCMHapproachreliesheavilyonteam‐baseddeliveryofprimarycare.10,15IncreasingtheincorporationofNPsandPAsintoteamshasbeensuggestedasoneapproachtoimplementingPCMHs.GiventhatimplementingaPCMHalsorequirescompletingnewtasks,suchaspopulationhealthmanagementandqualityimprovement,ithasbeenunclearhowtherolesofPAsandNPshaveevolvedtoaddressthesenewfunctions.TheresultsofthisstudysuggestthatPCMHimplementationhasnotdrasticallyaffectedtherolesofprimarycarePAsandNPs.AlargemajorityofNPsandPAsinPCMHsreportprimarycareproviderroles,withaminorityreportingsupplementalrolesonly.Seventy‐threepercentofrespondentsreporttheyactasaprimarycareprovidertoanaverageof930patients.ThisreportdidnotexaminethereasonsrelatedtothesmallpanelsizesreportedbyPAsandNPsactingasPCPs.ThehighproportionofPAsandNPsreportingaPCProlemaybeduetorequirementsforPCMHclinicianeligibility.16However,itmayberelatedtothefactthatmanyPAsandNPsperformmultipleroles(i.e.,PCPandsupplemental),andtheymayperformsupplementalrolesforalargerproportionofpatients.3Lessthanone‐thirdreporttheironlyroletobepurelysupplemental,suchasaproviderofsame‐dayvisits.MostNPsandPAsreporttheirrolesarewell‐definedandmatchedtotheirleveloftraining.Whenworkdidnotmatchtheirtraining,itwasmorefrequentlyworkthatcouldbedonebysomeonewithlesstrainingthanmoretraining.Accordingtomostrespondents,iftheydoperformworkthatcouldbecompletedbysomeonewithmoreorlesstraining,itisgenerallylessthan25%oftheirworktime.ThissuggeststhatatleastfromthePAandNPperspective,theirskillsareefficientlyusedwithoutsubjectingpatientstounduerisk.PAsandNPsworkinginaprimarycarerolesreportdifferentclinicaltaskdistributionsthanthosewhoworkinsupplementalroles.MostPAandNPsthatreportprimarycareproviderrolesrespondedthattheyperformawiderangeofprimarycareclinicaltasks,withahighproportionofvisitsfocusingonchronicillnesscare,preventivecareandmentalhealth.Incontrast,PAandNPsreportingsupplementalrolesreportedahigherproportionofvisitsspentonacutecare.TimespentonnewertasksassociatedwithPCMHsvarieswidely.CarecoordinationandmanagementareperformedbymostPAandNPs,butpopulationhealthandqualityimprovementarelesscommonlyreported.Thisstudydidnotexaminethereasonsforthesedifferences,butseveralpossibleexplanationsexist.First,carecoordinationandmanagementareconsideredoneofthefunctionsofprimarycare,andmayhavebeenapartofthePAandNProleevenbeforePCMHimplementation.4Second,populationhealthandqualityimprovementmaybeassignedtoanotherteammember.However,giventhereportedclinicstaffingpatternsandthefactthatPAandNPsareactingasprimarycareproviders,thisexplanationseemsunlikely.Morelikely,thesenewfunctionswerenotpartofthecurriculumforcurrentlypracticingPAsandNPswhoaveragedof11yearsofpracticeinourstudy.CurricularfocusandincreasedcontinuingeducationopportunitiesmayresultinmoreprimarycarePAsandNPstakingonthesenewPCMHtasks.

 

11  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

RoleswitchinghasnotplayedalargepartinPCMHimplementation,butrolechangesoftenresultedindissatisfaction.Lessthan20%ofrespondentsreportedarolechangewithPCMHimplementation.ManyreportedchangesincludedtheincreasedtasksassociatedwithPCMHimplementation,includingEMRrequirements,populationhealth,andqualityimprovement.AsmallnumberofPAandNPsreportedhavingrolesswitchfromthatofaprimarycareprovidertostrictlyasupplementalprovider.Ofthosethatofferedopinionsonthechange,themajorityweredissatisfied.ThisfindingwouldsuggestthatriskforPA/NPturnoverwithinclinicsconsideringPCMHimplementationmaybehigh,andthatclinicsmaywishtoconsiderconsultingPAandNPspriortoalteringroles.17

LimitationsSeveralsignificantlimitationstothisworkexist.First,thelowresponserateincreasestheriskofbiasedresults.18Second,thesurveycapturestheperceptionsofPAandNPs,whichisasubjectivesourceofdata.However,giventhatrolesarepatternsofbehavior,thepersonperformingtheroleisfrequentlyagoodsourceofinformation.19

VI.ImplicationsforPolicy1. ThefindingthatPAsandNPsperformdifferentpatternsofclinicaltasksinprimary

providerrolesthaninsupplementalproviderrolesmaybeusefulforworkforcemodelingofthetasksubstitutionpotentialofPAsandNPs.

2. PCMHPAandNProlesseemtobewellsuitedtocurrenttraining,butsincePAsandNPsreportnotmaximallyusingtheirtrainingupto30%ofthetime,teammodificationsandtrainingthatpromotetaskdelegationbyPAsandNPstostaffwithlesstrainingmightincreaseefficiencyofcare.

3. FewPAsandNPsreportperformingtasksforwhichtheyareunderqualified,butsincethesesituationsarepotentiallydangerous,provisionsforback‐upshouldbeavailabletothesePAsandNPs.

4. FewPAsandNPsarespendingsignificanttimeperformingsomenewerPCMHfunctionssuchaspopulationhealthmanagementandqualityimprovement.Increasedtrainingintheseareasmayimprovethelikelihoodofperformingsomeofthesefunctions.

5. AdditionalinvestigationiswarrantedtofindpotentialcausesandsolutionstothedissatisfactionreportedbythePAsandNPswhodidexperiencerolechangesassociatedwithPCMHimplementation.

References1. InstituteofMedicine.Crossingthequalitychasm:Anewhealthsystemforthe21stcentury.Washington,DC:

InstituteofMedicine;2001.

2. YarnallKS,OstbyeT,KrauseKM,PollackKI,GradisonM,MichenerJL.FamilyPhysiciansAsTeamLeaders:"Time"toSharetheCare.PreventingChronicDisease.2009;6:A59.

3. EverettCM,ThorpeC,CarayonP,PaltaM,GilchristV,SmithMA.TherolesofprimarycarePAsandNPscaringforolderadultswithdiabetes.JAAPA.2014;27:45‐9.

4. StarfieldB.PrimaryCare:BalancingHealthyNeeds,Services,andTechnology.NewYorkCity:OxfordUniversityPress;1998.

 

12  

CarolinaHealthWorkforceResearchCenterProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearchUniversityofNorthCarolinaatChapelHill

5. SibbaldB,LaurantM,ScottA.ChangingTaskProfiles.In:SaltmanRB,RicoA,Boerma,eds.Primarycareinthedriver'sseat?OrganizationalReforminEuropeanPrimaryCare.Berkshire,England:OpenUniversityPress;2006;2006.

6. HookerR,EverettC.Thecontributionsofphysicianassistantsinprimarycaresystems.Health&SocialCareintheCommunity.2012;20:20‐31.

7. EverettC,ThorpeC,PaltaM,CarayonP,BartelsC,SmithM.PhysicianAssistantsAndNursePractitionersPerformEffectiveRolesOnTeamsCaringForMedicarePatientsWithDiabetes.HealthAffairs.2013;32:1942‐8.

8. HolmesGM,MorrisonM,PathmanD,FraherE.TheContributionof"Plasticity"toModelingHowaCommunity'sNeedforHealthCareServicesCanBeMetbyDifferentConfigurationsofPhysicians.AcademicMedicine.2013;88:1877‐82.

9. RodriguezH,GiannitrapaniK,StockdaleS,HamiltonA,YanoE,RubensteinL.TeamletStructureandEarlyExperiencesofMedicalHomeImplementationforVeterans.JGenInternMed.2014:1‐9.

10. AmericanCollegeofPhysicians.JointPrinciplesofthePatient‐CenteredMedicalHome(PCMH)‐March2007.https://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf.

11. BodenheimerT,LaingB.Theteamletmodelofprimarycare.AnnFamMed.2007;5:457‐61.

12. SinskyCA,SinskyTA,AlthausD,TranelJ,ThiltgenM.'CoreTeams':Nurse‐PhysicianPartnershipsProvidePatient‐CenteredCareAtAnIowaPractice.HealthAffairs.2010;29:966‐8.

13. ScottMA,HitchB,RayL,ColvinG.Integrationofpharmacistsintoapatient‐centeredmedicalhome.JournaloftheAmericanPharmacistsAssociation.2011;51:161‐6.

14. CreswellJ.Researchdesign:Quantitative,QualitativeandMixedMethodsApproaches.ThousandOaks,California:SagePublications,Inc.;2009.

15. TheTransforMEDPatient‐CenteredModel.2009.(AccessedMarch28,2011,athttp://www.transformed.com/transformed.cfm.)

16. NationalCommitteeforQualityAssurance.Patient‐CenteredMedicalHome(PCMH)ContentExpertCertificationHandbook.Washington,DC:NCQA;2014.

17. RSHooker,KuilmanL,EverettCM.PhysicianAssistantJobSatisfaction:ANarrativeReviewoftheEmpiricalLiterature.JournalofPhysicianAssistantEducation.2015;26:176‐86.

18. AschDA,JedrziewskiMK,ChristakisNA.Responseratestomailsurveyspublishedinmedicaljournals.JournalofClinicalEpidemiology.1997;50:1129‐36.

19. BiddleBJ,ThomasEJ,eds.RoleTheory:CoceptsandResearch.NewYork,NY:JohnWiley&Sons,Inc;1966.

AuthorsChristineM.Everett,PhD,MPH,PA‐C,isanAssistantProfessorinthePhysicianAssistantProgram,intheDepartmentofCommunityandFamilyMedicineatDukeUniversityMedicalCenter.

BrandiLeach,MS,isaResearchAnalystinthePhysicianAssistantProgram,intheDepartmentofCommunityandFamilyMedicineatDukeUniversityMedicalCenter.

PerriMorgan,PA‐C,PhD,isanAssociateProfessorandDirectorofPAinthePhysicianAssistantProgram,intheDepartmentofCommunityandFamilyMedicineatDukeUniversityMedicalCenter.

AcknowledgmentsTheauthorswishtothankRachelFrantz,RachelMachtaandEricaRichmanforcompilingdataforthesamplingframe;SueIsleyforadministrativesupport;KatieGaulforreportdesignandlayout;andErinFraherandJanetFreburgerfortheirinputintothestudydesignandeditorialreview.

Appendix: State Characteristics

State Cen

sus

Reg

ion

MH

Pay

men

ts fo

r M

edic

aid/

Chi

p

UN

DE

RW

AY

(N

AS

HP

)*

Mul

ti-pa

yer

initi

ativ

es*

AC

A H

ome

heal

th p

lann

ing

gran

t*

AC

A a

ppro

ved

heal

th h

ome

stat

e

plan

am

endm

ents

*

Pay

men

t alig

ned

with

nat

iona

l or

stat

e qu

alifi

catio

n st

anda

rds*

Sha

red

Sup

port

Tea

ms*

Pop

ulat

ion

(mill

ions

)

Uni

nsur

ed (

%)*

*

Tot

al M

edic

aid

Spe

ndin

g F

Y 2

012

(bill

ions

)**

Ove

rwei

ght/O

bese

Adu

lts (

%)*

*

Poo

r M

enta

l Hea

lth a

mon

g ad

ults

**

Med

icai

d E

xpan

sion

**

Mor

e P

CM

H-r

elat

ed a

ctiv

ity**

% o

f cou

ntie

s th

at a

re P

C H

PS

A**

**

% P

As

in P

rimar

y ca

re**

***

Prim

ary

Car

e ph

ysic

ians

(# p

atie

nts

to 1

PC

MD

)***

Poo

r or

fair

heal

th (

%)*

**

Une

mpl

oym

ent (

%)*

**

Sel

ecte

d fo

r su

rvey

s Arkansas Midwest x x x

x

15 4.1 68.7 38.9 Yes x 0.73 40.7 1586 19 7.3

Idaho West x x x x x

1.6 14 1.5 62.5 36.2 No

1 42.9 1683 15 7.1

Maine Northeast x x x x x x 1.3 10 2.4 64.2 37.3 No x 0.94 30.3 935 13 7.3

Michigan Midwest x x

x x 9.8 11 12.5 65.6 37.8 Yes x 0.96 27.2 1268 14 9.1

Oregon West x x

x x

3.9 13 4.6 61 39 Yes x 1 35.4 1115 14 8.7

Not

sel

ecte

d fo

r su

rvey

s

California West

x

38.1 15 50.2 60.3 39.1 Yes

0.98 33.8 1326 18 10.5

Kentucky South

x

4.3 13 2.7 66.9 38.5 Yes

0.68 31.1 1560 21 8.2

Minnesota Midwest x x x

x x 5.4 7 8.9 63 32.5 Yes x 0.71 33 1116 11 5.6

Nebraska Midwest x x

x

1.8 10 1.7 65 31.8 No

0.67 39.6 1404 12 3.9

Nevada West

x

2.7 20 1.7 62.5 36.9 Yes

1 32.9 1742 17 11.1

New Jersey Northeast x x x

x

8.8 12 10.4 61.6 30.2 Yes

0.67 17.8 1174 15 9.5

North Carolina South x x x x x x 9.6 16 12.3 65.8 32.1 No x 0.87 31.8 1462 18 9.5

Pennsylvania Northeast x x

x

12.8 10 20.4 64.9 35.7 Yes x 0.88 23.4 1244 14 7.9

Texas South

26 20 28.3 65.1 34.1 No

0.85 37.2 1743 18 6.8

* National Academy for State Health Policy. www.nashp.org. Accessed February 2, 2015

** Patient-Centered Primary Care Collaborative. https://www.pcpcc.org/resource/medical-home-and-patient-centered-care-medicaid-map. Accessed February 2, 2015.

*** County Health Rankings. 2014. Robert Wood Johnson Foundation. http://www.countyhealthrankings.org/.

**** Health Resources and Services Administration. Data Warehouse: HPSA Find. http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx. Accessed February 2, 2015

***** National Commission on the Certification of Physician Assistants. 2014 Statistical Profile of Certified Physician Assistants. March 2015.

13

C

arolin

a Health

Wo

rkfo

rce Research

Cen

ter P

rogram

on

Health

Wo

rkfo

rce Research

& P

olicy

C

ecil G. Sh

eps C

enter fo

r Health

Services R

esearch

Un

iversity

of N

orth

Caro

lina at C

hap

el Hill