What Is the Role of Advanced Practice Practitioners in Patient Care?

Expanding patient access to care

The US is experiencing a patient access to care problem at the same it’s experiencing a clinician shortage problem, two issues that are likely tied together. When there aren’t enough physicians in an area to see patients, it is likely many patients will go without care, or at least experience long wait times.

Advanced practice practitioners are poised to fill that gap, data has shown. In 2018, United Health Group reported that nurse practitioners and physician assistants could fill the primary care provider shortage by 70 percent should they get full practice authority.

On average, 16,000 nurse practitioners graduate from a primary care education program, and by 2025 UHG predicts the number of NPs practicing primary care will increase by 47 percent. For PAs, primary care specialists are expected to increase by 38 percent.

If granted full scope of practice, NPs could help cut the number of people living in a county with a PCP shortage from 44 million to 13 million nationwide. In rural regions, that proportion could decrease from 23 million to 8 million, a near 65 percent reduction, UHG said.

NPs and PAs have a track record of filling those physician shortage gaps, separate data has shown. Following Affordable Care Act passage, which expanded access to insurance and thus access to care patients across the country, NPs and PAs were instrumental in managing that influx.

The 2019 report published in Annals of Family Medicine showed an increase in appointment availability, largely driven by NPs and PAs having open appointment availability. This mitigated potential bottlenecks when more patients gained health payer coverage.

That manpower also came to bear during the onset of the COVID-19 crisis, which was characterized by serious shortages in patient care access and tight staffing. That left Sophia Thomas, DNP, APRN, FNP-BC, PPCNP, FAANP, who presided over the American Association of Nurse Practitioners (AANP) at the start of the pandemic, to call on state leadership to waive nurse practitioner scope of practice laws.

"It's more urgent than ever that governors lift these barriers,” AANP President Sophia Thomas, DNP, APRN, FNP-BC, PPCNP, FAANP, said in a statement. "At this critical time, we urge states to act decisively to eliminate these needless barriers to practice and enable NPs – active, inactive or retired in good standing – to combat this crisis head on." 

At publishing time, 24 states and 2 US territories allow for full practice authority for nurse practitioners. For PAs, 31 states allow supervision policies to be determined at the practice level, while the remaining states determine it at the state level.

Leading SDOH communication, referral work

NPs and PAs bring more to the table than increasing the provider workforce; they also are in a unique position to forge deep relationships with patients. And in doing so, they can work to uncover important non-clinical information about patients, like social determinants of health information.

“We know that people's ZIP code is very much a greater indicator of healthcare outcomes than their genetics,” Thomas told PatientEngagementHIT in a separate interview. “And so, we look at the social factors that impact their ability to care for themselves. Do they have access to healthy food? Do they have transportation to get to their medicine, or to get to any specialist appointments? Is their house safe with them?”

Typically, patients place deep trust in their relationships with their nurses, and according to Thomas, being an NP is an extension of that. Through those strong relationships, NPs are able to uncover the factors at home that are going to impact a patient’s ability to healthy, like living close enough to a grocery store or having access to transportation.

And from there, the NP and rest of the nursing team is able to spearhead the SDOH referral process, helping to connect that patient with a rideshare deal or a home meal delivery program so the patient can get nutritious food on the table.

PAs, who rely strongly on a multi-disciplinary care team and are integral to building out team-based care, also have unique abilities to drive health equity, Tonia Poteat, PhD, MPH, PA-C, DFAAPA, said in a 2020 American Academy of PAs article.

“I noticed that many of the people I knew in the community reported having stigmatizing experiences,” she said in the interview article. “And I worked at the clinic and I knew the other people who worked there, and they all seemed like great people who would never intentionally treat people poorly.”

“That’s where I got interested in what stigma really was, how it works, and what we can do about it,” Poteat continued.

Boosting patient satisfaction rates

Perhaps the most measurable benefit of nurse practitioners and physician assistants is on patient satisfaction. Study after study has found that patient satisfaction with advanced practice practitioners is on par with, or even better than, that with physicians.

In 2019, a literature review published in BMC Human Resources for Health found that physician assistants saw patient satisfaction rates that were at least equal to patient satisfaction scores for physicians. That was consistent across all 25 studies included in the literature review, the authors said.

Similar trends have been observed for nurse practitioners, who boast equal or better patient satisfaction scores than their colleagues, studies have shown.

These findings are likely at least somewhat driven by the fact that PAs and NPs can meet patient care needs. Patients report high satisfaction when they feel their clinician—whether that clinician be a physician or an advanced practice practitioner—can address their concerns and mitigate symptoms.

According to Bianca (Belcher) Duff, MPH, PA-C, vice president of Clinical Operations at Steward Health Care, patients are happy to see a PA, so long as the practice not discredit the PA’s expertise.

“It used to be that when a patient called in and asked to see Dr. Smith, they were told, ‘Well, his first appointment is three months out. We could put you with one of the mid-levels instead,’” Belcher said at Xtelligent Healthcare Media’s Value-Based Care Summit: Population Health event in 2018.

“If I’m a patient, I’m immediately going to say, ‘I don’t want to see a mid-level provider.  I want a high-level provider!  I only want the best, and clearly a mid-level can’t provide that.’”

Then organizations emphasize the credentials of their advanced practice practitioners, patients are happy to see them and often come away with high satisfaction.

“They started to ask, ‘Would you like first available appointment with our PA, Jane? She’s highly trained and has been here for years, and she can do this, this, and this for you. The first available appointment with her is tomorrow. Or if you want to wait, you can have Dr. Smith in three months,’” Belcher added.

More than nine times out of ten, patients would pick the first available appointment, said Belcher.

It will be essential for medical leaders to assess the value APPs bring to the patient care encounter, and the overall patient experience. By closing patient care access gaps by fortifying the provider workforce, zeroing in on social determinants of health, and supporting good patient satisfaction scores, advanced practice practitioners can be of benefit to team-based care efforts.