APP Care Models in Headache Practice

Introduction

Advanced practice providers (APPs) play an essential role in the delivery of healthcare services. Both nurse practitioners (NPs) and physician associates (PAs) represent a rapidly growing workforce.  In 2023, there were 385,000 board certified NPs and 178,708 board certified PAs1,2. The national growth seen in APPs has not been unnoticed by headache practices. APP membership within the American Headache Society (AHS) is a significant and important growing membership subtype. In large part, this growth is representative of changes within clinical practice settings throughout the country. Practices that utilize models of care that include APPs could see increased patient access and enhanced care delivery through the unique skill set APPs bring to the team.               

Successful transition to practice is a key to maintaining delivery of high-quality care while also providing more access to patients.  Planned transition to practice is also thought to enhance retention of healthcare providers3. There is not a single approach to address transition to practice; however, the goal of transition to practice is to enhance clinical skills and confidence—understanding the current state of the new hire’s neurology clinical knowledge is helpful when determining how to arrange ongoing learning.

The idea of team-based care is rooted in individual team members understanding the strengths and limitations of each team member4.   Understanding what each team member brings to the table and taping into those talents is important to developing strong teams. Transition to practice is not a quick process and should be planned over a few months to one year. Frequent reassessment is needed and the transition to practice plan may need revisions. 

Benchmarks

Specific benchmarks should be established to evaluate outcomes of transition to practice. The outcome assessment can be divided into three categories: clinical competency/clinical outcomes, financial productivity, and technical skills. Objective measurement such as direct observation of exam with associated skills check off, patient satisfaction scores, and quality improvement dashboards can plan a role in determining if readiness for practice has occurred.

Care Models

There are several models of care that enable clinics to see more patients while not invalidating trust and respect between provider types.

Shared Model

This model is often utilized during the transition to practice as well as with experienced APPs. The shared model relies heavily on the team as the APP and neurologist will be working together to see new patients. This is helpful in two ways, first it further develops expertise among APPs and secondly it helps patients understand what team-based care looks like and how their care will be delivered within a team5.

Follow-up Model

There are additional models of care that allow for more autonomy among team members. In this model, the APP sees follow-up encounters allowing the neurologist to see new patient encounters. 

Consult Model

In a reversal of the follow-up model, the specialist as a consult model consists of the APP first seeing the patient. The APP examines, educates, and orders testing and then the patient returns to see the neurologist who will interpret the testing and establish the diagnosis—e-consults can fall into this category6. 

Collaborative Care Model

The final care model and arguably the ideal model of care for neurologist/APP teams is the collaborative care model.  This model relies on the trust and respect built in the transition to practice process. The collaborative model utilizes interprofessional collaboration and shared decision making. In essence, both team members are empowered to practice to the fullest scope of their practice. 

Summary

Headache medicine continues to face an access challenge—there are not enough physician type providers to meet the demands of the patient population.  There are a variety of potential solutions including team-based care models that could be deployed to meet this challenge. When considering using team-based care models, mindfulness around APP transition to practice is needed and transition to practice should be planned and agreed upon by the team. There are many potential solutions to access; however, there are a growing group of providers who are engaged and may be key to addressing this challenge.

References

1. During National Nurse Practitioner Week, AANP Applauds NPs for Their Incredible Contributions to Patient Health, Celebrates Continued Expansion of the Workforce. Accessed November 26, 2024. https://www.aanp.org/news-feed/nurse-practitioner-profession-grows-to-385-000-strong#:~:text=The%20ranks%20of%20NPs%20grew,strengthen%20the%20health%20care%20system.
2. National Commission on Certification of Physician Assistants I. 2023 Statistical Profile of Board Certified PAs, Annual Report. 2024;
3. AAN Position Statement: Neurology Advanced Practice Providers. 2020;
4. Poghosyan L, Norful AA, Martsolf GR. Primary Care Nurse Practitioner Practice Characteristics: Barriers and Opportunities for Interprofessional Teamwork. J Ambul Care Manage. 2017 Jan/Mar 2017;40(1):77-86. doi:10.1097/JAC.0000000000000156
5. Aocnp A, Msn, Austin, Annie, Cnp J, Kellyann, Mha K, Diana, et al. A Study of Advanced Practice Provider Staffing Models and Professional Development Opportunities at National Comprehensive Cancer Network Member Institutions. Journal of the Advanced Practitioner in Oncology. 2021;12(7)doi:10.6004/jadpro.2021.12.7.56. Clevenger C, Clark, C., Brown, A., Villinger, T., Lyron, S., Bondds, K., & Cook, C.L. . Advanced Practice Providers in Dementia Care: Optimizing All Providers on the Care Team. Practical Neurology. 2023;