Expanding the Role of APPs Helps Both Patients and Physicians

Cleveland Clinic’s otolaryngology and head and neck surgery department has historically focused on tertiary and quaternary care. This focus on highly-subspecialized complex surgical care is, and will always remain, a key distinguishing feature of the Cleveland Clinic. Most residents who graduate from Cleveland Clinic and similar top-tier academic training programs pursue subspecialty training. Advanced cancer care, complex head and neck reconstructive surgery and both interior and lateral based surgery fall within these domains.

At the same time, Cleveland Clinic’s Head & Neck Institute aspires to provide the entire spectrum of care for all conditions related to the head and neck. Much of this care across the nation is provided by otolaryngologists who choose not to specialize, and these “comprehensive otolaryngologists” serve a vital function in society. This practice model has been challenged in recent years by a variety of factors. In addition to the popularity of subspecialization, many private practices have undergone consolidation. In Northeast Ohio, very few private otolaryngology practices exist with most having been incorporated into the academic system. Payment reform, along with the increase in burden of regulation, have led to pressures on non-specialist surgeons to see an increased number of patients. In otolaryngology, this means that a reasonable percentage of one’s practice may end up focusing on non-surgical, or “medical” otolaryngology.

Patrick Byne, MD, MBA, the Chairman of the Head & Neck Institute, views these dynamics as concerning. He believes that the institute can use its resources more effectively and efficiently by rethinking how to provide the entire spectrum of care for otolaryngology head and neck surgery. One of these solutions is the expansion of advanced practice providers (APPs).

“Most surgeons really like to operate. Many conditions that fall within the scope of practice for comprehensive otolaryngology are non-surgical in nature. We believe that investing in top of license activity is smart for a lot of reasons,” says Dr. Byrne. “We’re doing so in a number of ways. One way is that we’re dramatically expanding the number of APPs we have. We have more than tripled the number of nurse practitioners and physician assistants that work within the Head and Neck Institute over this past year. I have been blown away by the quality and professionalism of the APPs at Cleveland Clinic’s Head & Neck Institute.”

Dr. Byne says that the institute intends to keep growing this cadre of providers, and that they’re training them across the spectrum of otolaryngology and neck surgery. A certain percentage of these APPs will function as comprehensive APPs, but there will also be APP who will function as highly-specialized providers across the sub-specialties, including facial plastic surgery APPs, head and neck cancer APPs, rhinology APPs, laryngology APPs and pediatric APPs.

Improving access for patients, freeing up time for surgeons

The increased usage and incorporation of APPs into the care path will allow the institute to rework its patient access flow and make sure that patients who need to be seen are seeing the right provider quickly. “As our comprehensive APPs develop their capacity and skillset, they will become the way for many patients to initially encounter our institute,” says Dr. Byrne. “This is not a novel concept, although it is certainly being leveraged to a greater degree in other fields than ours, but we are confident this is the right way to go. Instead of patients waiting a long time to see a surgical subspecialist who really doesn’t focus on the problem that they’re coming with, we’ll have an experienced and highly-trained provider who really focuses on the problem that they’re presenting with and who can meet the patient more quickly and spend more time with them. In a sense, we’re almost clarifying medical otolaryngology versus surgical otolaryngology.”

Dr. Byrne sees a great number of benefits for both patient and provider by turning to this model of care. He believes that as the institute develops our ability to manage care this way, they’re going to see that the percentage of patients in the clinics of the comprehensive otolaryngologists who are surgical patients are going to progressively increase over time. Patients will get to see the right type of provider, who cares passionately about the condition because they have devoted their life to treating these conditions, and providers get to practice the kind medicine that really motivates them. The average cost for care will go down as well as the institute transfers this care into the hands of APPs. Surgeons are benefited because as the APPs take on more clinical responsibility, the ratio of time that surgeons spend in the clinic versus OR starts to shift more in favor of more OR time and a little less clinic time. Dr. Byrne believes this will help Cleveland Clinic not only recruit the most talented people but also retain them.

Dr. Byrne points to back pain as a condition in which a lot of centers around the country have learned intelligent ways to quickly triage incoming patient calls, and based on a fairly concise number of questions direct the patient towards either a medical provider or a surgical provider. This approach speeds up access, increases the quality of care, improves the quality of the experience, improves the provider job satisfaction and lowers the overall cost of care.

“We envision a future in which APPs are integrated within a team of virtually all aspects of care. One example is the management of urgent consults,” says Dr. Byrne. “Often times, patients present with peritonsillar abscesses or significant nosebleeds, and they just can’t access a specialist, their care is delayed, and they have to be transferred. Our surgeons and APPs believe that we can achieve at least an equivalent level of quality and safety for epistaxis management and peritonsillar abscess drainage by experienced and highly trained APPs with oversight, as we currently do with our current model. Many of our app applicants are excited that they can be proceduralists as well. So while I do frame it in part as medical versus surgical, which is APPs versus surgeons, there is this hybrid set of diagnoses, which really are procedural, which APPs we envision managing expertly moving forward.”

Where the program is presently

Marilyn Davies, a nurse practitioner in the Head & Neck Institute, is the director of the Institute’s APP program and has spearheaded its expansion. “When I had my first meeting with Dr. Byrne and Trish Hirkala PA-C, who was our APP director at the time, discussed the roles of our APPs and this expansion plan he envisioned. After planning and meeting with staff, we put the wheels into motion to hire and onboard these new providers.”

“The APPs have spent five months just in training,” says Davies. “They have been rotating through with shadowing physicians and working side-by-side with them in clinic. There’s also a very big educational component to the program involving readings and lectures. Then, the transition into a fully functioning clinic is very gradual.”

Davies explains that the APPs in the program are all currently stationed, and while they are only seeing a few patients per clinic day, the hope is that they will eventually see 15 patients per day. “They’re also co-located with the surgeon,” she says. “So any single APP can go over to them and ask a question. In fact, the surgeon can also pop in at this stage, if it’s necessary. The feedback I’ve gotten from the physicians and the APPs is very positive. We’re approaching this in a really smart way that we feel will really pay off for our patients.”