Physician Assistant and Nurse Practitioner Roles in ... · University of North Carolina at Chapel...
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This work is funded through HRSA Cooperative Agreement U81HP26495‐01‐00: Health Workforce Research Centers Program. Carolina Health Workforce Research Center Program on Health Workforce Research & Policy Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill http://www.healthworkforce.unc.edu Physician Assistant and Nurse Practitioner Roles in Patient‐Centered Medical Homes Christine M. Everett, PhD, MPH, PA‐C; Brandi Leach, MS; Perri Morgan, PhD, PA‐C Research Brief, February 2015 I. Executive Summary/Key Findings Team‐based care involving physician assistants (PAs) and nurse practitioners (NPs) is one recommended strategy for improving access and quality and reducing cost in the patient‐centered medical home (PCMH). PAs and NPs can, and do, perform a variety of roles on primary care teams. This suggests that there is plasticity within the professions and between PAs, NPs, and physicians. Primary care PA and NP clinical roles can be defined by the approach to care distribution between PA or NP and the collaborating physician. When PAs and NPs provide the majority of primary care and perform all of the functions of primary care for a group of patients in a manner similar to physicians, they are acting as a primary provider of care. When PAs and NPs provide only a subset of the functions of primary care, such as providing same‐day acute care visits only, they are acting as a supplemental provider. While some studies have described PA and NP roles within a given PCMH, it is unclear the extent to which different PA and NP roles are being implemented in PCMHs nation‐wide. This project aims to describe PA and NP roles currently implemented in primary care practices participating in public and/or commercial PCMH programs, and to assess primary care PA and NP perceptions of role changes due to PCMH implementation. CONCLUSIONS AND IMPLICATIONS FOR POLICY 1) The finding that PAs and NPs perform different patterns of clinical tasks in primary versus supplemental provider roles may be useful for workforce modeling of the task substitution potential of PAs and NPs. 2) PCMH PA and NP roles seem to be well suited to current training, but since PAs and NPs report not maximally using their training up to 30% of the time, team modifications and training that promote task delegation by PAs and NPs to staff with less training might increase efficiency of care. 3) Few PAs and NPs report performing tasks for which they are underqualified, but since these situations are potentially dangerous, provisions for back‐up should be available to these PAs and NPs. 4) Few PAs and NPs are spending significant time performing some newer PCMH functions such as population health management and quality improvement. Increased training in these areas may improve the likelihood of performing some of these functions. 5) Additional investigation is warranted to find potential causes and solutions to the dissatisfaction reported by the PAs and NPs who did experience role changes associated with PCMH implementation.
Transcript of Physician Assistant and Nurse Practitioner Roles in ... · University of North Carolina at Chapel...
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.
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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.
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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.
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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
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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
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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
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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
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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
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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
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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.
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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.
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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
