Table. Advanced Practice Providers in Oncology Practice

Advanced practice providers (APPS) are playing anincreasingly important role in oncology care. The need for services is increasing, but there are not enough oncologists entering the profession. A deficit of 1487 oncologists is projected by 2025.

 In addition, oncologists are seeing more patients with comorbidities, requiring more physician time. And, although patient outcomes have improved thanks to the efficacy of new treatments, patients stay in the healthcare system longer. Additionally, the aging population and increased access to care have intensified the demand for services. Because of all these factors combined, the burden on oncologists is becoming unmanageable, leading many practices to turn to APPs (Table. Figure

The decision to hire an APP often occurs soon after a practice realizes its providers are overbooked. As the average number of days until first appointment gets longer and patients are referred to competitors, practices react by hiring an APP.

However, this snap decision often leads to disappointment, as an APP typically cannot instantaneously bridge the provider gap. A better business response is to anticipate growing patient volumes as well as an aging workforce and factor those into succession planning. It is sometimes possible to replace a retiring physician with 1 or 2 APPs. By preplanning 4 or 5 years ahead, practices can anticipate when another provider will be needed, allowing ample time to find and on-board the right person.

Across The US Oncology Network, 2 APP healthcare delivery models are most prevalent: independent visit and shared visit. While both are collaborative, the most popular is the independent visit model. Under this, APPs manage their own clinic, spending most of their time on follow-up care. Interaction with supervising physicians occurs as needed, such as when a change in treatment plan is required. Often, a patient will see the APP between physician visits. Ideally, APPs have their own nursing support, their own offices, and dedicated exam rooms. This staffing model provides a high degree of independence and job satisfaction. Essentially, APPs run their clinics simultaneously and independently, but there is oversight, support, and collaboration from oncologists.

This delivery model is the best method by far for optimizing APP performance and productivity. Unfortunately, it is sometimes not fully taken advantage of because some physicians have difficulty letting go of their patients. Oncologists become competitive with the APP, creating an unproductive environment. When this happens, APPs generally lose their independence and are at risk of diminishing job satisfaction. They may be required to share the physician’s clinic—seeing the same patents with the physician simultaneously. Consequently, patients end up being cared for by 2 providers during their visits. Productivity for both providers, as well as patient volume, does not increase.

APPs get discouraged with this situation because rather than providing care, they spend most of their time following the physician, essentially becoming an expensive scribe. When an APP is not allowed to practice to credentialed capability—or top of license&mdash; seeing patients independently and managing a clinic, the practice is wasting a valuable resource.

Because the goal of adding an APP is to manage a higher volume of patients while maintaining the quality of care, this competitive behavior is also counterproductive. Ideally, physicians should focus on getting new patients into the practice and being available to challenging patients. By allowing APPs to work independently, physicians can focus on priorities and leave the handling of follow-up visits, supportive care programs, and urgent-care patients to the APPs.

Providing support to help APPs succeed is critical. These highly skilled providers are in strong demand and can easily find employment elsewhere if they become dissatisfied. The following are recommended best practices and tips to ensure that APPs in your practice perform to the best of their ability and remain satisfied with their jobs:

Have reasonable expectations for a new APP.

 Many APPs have no oncology experience, and some come right out of training. They cannot be expected to immediately jump into clinic and manage a large patient load.

 One APP supporting 2 physicians is ideal. This allows APPs to become familiar with the physicians’ care delivery methods so they can provide similar care to patients, enabling continuity of care. It also helps APPs become more productive. Seeing many of the same patients multiple times leads to better outcomes than constantly working with unfamiliar patients.

Be prepared to spend time and effort on-boarding an APP. 

Oncology is complex, and unless APPs previously worked in the field, they must become familiar with the basics of cancer care. On-boarding typically involves a lot of shadowing, working beside a seasoned APP, a physician, or both. Spending time with the pharmacist, the infusion team, and the staff involved with business processes can also help APPs understand how a practice operate.

	The US Oncology Network offers an intensive on-boarding program several times a year to help APPs get off to a strong start. They gain expertise in various hematology and oncology topics so they are prepared to manage patients.

	They also have the opportunity to network with peers and develop mentorships.

	Anecdotal evidence across The US Oncology Network suggests that APPs in community oncology require about 2 years of experience before they will feel prepared to handle any patient they might encounter. Although they come with prior healthcare experience, it takes time for them to achieve a level of confidence in oncology.

Make sure APPs are practicing at the top of their license.

 APPs are highly trained and educated. If they are relegated to performing mundane tasks that less qualified staff can do, APPs are likely to become dissatisfied. This would also be a waste of a valuable resource.

Build a practice culture that respects and includes APPs.

 APPs are sometimes left out of various practice activities, as they operate in a gray area—their responsibilities fall somewhere between those of a physician and a nurse. To be successful in the long term, APPs must be grouped with physicians and receive the same level of support. This means having their own offices, their own exam rooms, and dedicated support staff. Their names should be on their office doors, and they should be included on the practice website with a picture. Practices should strive to include them in various initiatives and to serve on practice committees and leadership teams whenever possible, demonstrating that their input is valued.

Provide lifelong learning opportunities. 

Enabling APPs to grow and learn throughout their career is vital to fostering job satisfaction. Support their growth by encouraging them to attend conferences, discussing cases with them, including them in committees and tumor boards, and seeking other ways to keep them involved and excited about their work. Have good processes in place to provide feedback, and encourage their suggestions as well.

Cancer care today is very challenging, as practices are tasked with providing quality care that is also cost-effective. Add to that the complex requirements of value-based care, as well as the increasing patient volume, and the situation can seem overwhelming.

APPs offer a viable solution, helping practices meet the growing demand for services while maintaining and enhancing quality care. However, APP productivity and performance can be optimized only when APPs are allowed to operate independently, seeing their own patients and managing their own clinics. This collaborative delivery model empowers APPs to do what they do best—practice medicine―which is what they are trained for and do quite well.

American Society of Clinical Oncology. The state of cancer care in America, 2014: a report by the American Society of Clinical Oncology.

2014;10(2):119-142. doi: 10.1200/JOP.2014.001386.

New survey of advanced practice providers in oncology launched [press release]. Alexandria, VA. American Society of Clinical Oncology. February 24, 2017. www.asco.org/advocacy-policy/asco-in-action/new-survey-advanced-practice-providers-oncology-launched. Accessed March 20, 2018

Advanced Practitioner Society for Hematology and Oncology. Advanced practitioners in oncology: meeting the challenge. APSHO website. www.apsho.org/page/AbouttheAP.

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