Good afternoon, everyone. Thank you for coming in today. We are going to be talking about the role of APPs, or Advanced Practice Providers, in neuromuscular practice. Specifically, this is about advanced practice providers, not apps, which was a fear of mine when we named this talk. But rest assured, hopefully we'll have a little bit of information for everybody no matter what year you're coming in for. Before we get started here, just a show of hands, who here has worked with an advanced practice provider before? Amazing. And who here is an APP? Awesome. Great. Thank you so much for coming. I know this talk seems like it's geared toward physicians, but really want to bring together physicians and APPs no matter what your role is. I think we can all get something out of this presentation. My name is Maggie. I am a physician assistant, and I'll be kicking us off talking about APP's scope of practice and shared practice models in clinic. We'll get started. Here are my disclosures. So just a little bit about me, I want to introduce myself and kind of talk about my journey to my particular role. I'm a physician assistant. I graduated from Chatham University in Pittsburgh, Pennsylvania, where I developed a great interest in neurology. I had a great elective neurology rotation that really drew me towards the field. After I graduated, I worked for a year in orthopedic surgery before transitioning to my role in the neuromuscular division at Brigham and Women's Hospital. I've been in my current role for five years, and I work with a group of 11 physicians in our division. I have my own panel of patients, and I see both new consults and follow-up appointments over six half-day blocks over the course of the week. I also work alongside my physician colleagues supporting our inherited neuromuscular disease clinic, as well as our IGM-associated neuropathies clinic. I also wear a hat running our APP-run lumbar puncture clinic, and I also serve as the primary preceptor for PA students coming to our department. The one thing I really enjoy about my role is the support and the respect that I have for my physician colleagues. I work with a great team, in my biased opinion. I have a very high level of autonomy in my practice, but I also feel very comfortable seeking support and resources from my colleagues. So my objectives today are to define advanced practice providers, or APPs, and talk a little bit about scope of practice, which differs between nurse practitioners and physician assistants. I'm going to discuss some existing legislation that exists for providers within our affiliate organizations, and then I'm going to present some real-world data and some testimonials from some of our colleagues that actually work in the field. So this slide gives a basic overview of physician assistants and nurse practitioners. Despite what I initially thought, PAs and NPs, actually, the career path started at a very similar time in history, and both careers graduated their first class within the same one-year period. I think PAs have a very strong, well-documented history starting from the GI veterans that came home from Vietnam, the medics who didn't necessarily have medical school training but also wanted to provide clinical care were given an outlet to practice through PA programs. There's a little less history on nurse practitioners, and it's something that the field is actively trying to find out more information, but from my understanding, I read that nurse practitioners, the career was started by two physicians that actually wanted to expand practice for pediatrics, which was a big growing field at the time, considering the baby boomer generation coming forward. So both programs do allow their graduates to graduate with a master's degree, although nurse practitioners can go on to earn a doctorate degree, a DNP. PAs graduate with the ability to practice, essentially, in any field. Their curricula is geared toward general medicine, primary care, hospitalist medicine, and surgical field, since those are the three top areas where PAs are practicing today. Once they are licensed, PAs maintain their certification by passing a board exam every 10 years and then keeping up with CME requirements every two years. Nurse practitioner programs allow for some subspecialization within family medicine, seeing all age groups, adult gerontology, primary care, acute care, psych, and women's health and pediatrics. Once board certified, a nurse practitioner can practice in any state, and they keep up with CME requirements to maintain their licensure. So scope of practice governs the relationship between APPs and their supervising, also called collaborating physicians. Both PAs and NPs are trained and licensed to see patients, obtain a history and exam, order and interpret diagnostics, and prescribe treatments. The extent to which we can do this is governed by scope of practice laws. Now, the PA and NP communities each have a unique approach to scope of practice legislation, which kind of leads to a variability in our scope of practice laws state to state. The biggest difference is that nurse practitioners gear their scope of practice legislation, aiming to allow scope of practice to be determined by the state board of nursing level, where PAs scope of practice legislation aims to try to have scope of practice determined at the level of an individual institution or practice. The American Academy of Nurse Practitioners published this intuitive tool to outline the scope of practice for nurse practitioners across this country. The 22 states that are highlighted in green are those in which nurse practitioners can practice to the fullest extent of their license, which is defined as the provider is able to evaluate patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing, rather than under the direct supervision of collaborating or supervising providers. Yellow states will restrict one piece of this practice. And then the states highlighted in red will do restrict one piece of the scope of practice, as well as require a supervising or collaborating provider to be involved in patient care. The American Academy of Physician Assistants has devised six key elements to modern PA practice to define their scope of practice. So those include licensure as a regulatory term, as opposed to certified or registered, full prescriptive authority of medications, adaptive collaboration requirements, which just determine the degree in which a physician needs to be involved in terms of the delivery of patient care. Scope of practice determined at the level of the practice, which is their whole goal. Co-signature requirements determined at the practice level. So there are some states and institutions which require physicians to co-sign or review patient charts that a PA has written. And then finally, the number of PAs a physician may collaborate with is determined at the practice level. So every PA does need to have one collaborating physician on their license. However, one physician can collaborate with multiple PAs, and that's determined at the practice level. So APPs actually function in clinic very similarly to our physician colleagues, though our encounters have a couple different billing schemas to choose from. So we have shared and split visits, we have independent visits, and we have incident two visits. The shared and split visits is a patient visit that's usually seen on the APP schedule with the APP as the billing provider, and the physician is involved in the patient care delivered in the room with the patient. So the physician must be in the room, there must be a collaborative discussion with the patient reviewing aspects of the physical exam and the treatment plan. In many states, APPs can see patients independently and bill for their visits with their own NPI number. In these visits, the reimbursement is limited to 85% of the full allowable physician payment from Medicare, whereas independent, or sorry, shared split visits and incident two visits do allow for the 100% reimbursement. Finally, incident two encounters refer to specifically follow-up visits that are seen independently by the PA, that are, sorry, APP, that are a strict continuation of care that has been determined by the physician. While it does allow for 100% reimbursement, it does have very specific documentation requirements to be considered incident two, and not every institution or practice utilize these, but more information about incident two can be found on CMS websites or PA or NP literature. So I wanted to discuss APP recognition by other organizational stakeholders. The American Academy of Neurology took a special interest in APPs and drafted this position statement first in 2015, and then revised it in 2020, kind of discussing APPs in the context of the supply and demand deficit for neurologists in this country. The EAN has recognized APPs as invaluable resources to enhance neurology practice. While the goal is basically to view APPs as a part of the healthcare team and emphasizing a team-based approach to care, speaking to the fact that APPs cannot replace the need for neurologists, but we can alter the neurologist role in patient cares to enhance practice. The American Academy of Physical Medicine and Rehabilitation has also drafted a position statement, which was published in 2019 by their governors. The position statement does emphasize APP utilization in physiatrists-led team-based care, citing the years of specialized training that physiatrists must undergo to practice. The AAPMNR opposes independent practice of APPs in rehabilitation care. However, the academy does support APP utilization and recognizing that APPs provide a critical pathway to maximize the workforce. So as of this year, and specifically within the last month, the AANEM has actually published a position statement about the roles of APPs. We had a work group that was put together to draft a position statement that was just approved by the board as of September. And we're very, very excited to share this news today. Our goal was to have APPs recognized as providers of neuromuscular and rehab medicine care. The position statement includes a discussion of APP scope of practice as it relates to our field, emphasizing, again, a team-based care model between physicians and APPs, discussing the importance of APP initial and ongoing on-the-job training in order to create successful careers for us, and outlining the ways that the AANEM can help support us as a career. So I recently conducted a small survey of APPs, just very biased data, seven APPs that I knew, just kind of taking a look at what our practice activities are in terms of what kind of patients we're seeing, what kind of appointments we're seeing. So this is some preliminary data that I have from that. It appears that the majority of us do see adults, although some of us do see children, and neuropathy and myasthenia do seem to be the top conditions that we see in our practice. Most commonly, this group of APPs are conducting independent follow-up visits, though more than half will see new consults, and I particularly find it interesting that there's an equal distribution between new shared and new independent visits. In the future, it would be very informative to conduct a more comprehensive inventory of APP practice so that the AANEM and employers of APPs can help further explore APP utilization and create educational resources for us, so that's something that I foresee down the pipeline. All right, so aside from this limited data set, I thought it would be most helpful to kinda highlight some of the APPs who work within the field of neuromuscular medicine. So I have testimonials from three APPs who have graciously agreed to provide some insight into their experience. The first one I have here is Deb Guntram. She is a nurse practitioner who works for the University of Rochester Department of Neurology. She's worked in her current role in the Neuromuscular Disease Center since the year 2000, and she provides care to both children and adults with neuromuscular disease, and she also works in research as well. So I'll let her tell you more. Hi, my name is Deb Guntram. I'm a family nurse practitioner at the University of Rochester Medical Center in Rochester, New York. I have been with the practice for a little over 24 years. I see all patients, both children and adults, with inherited and acquired neuromuscular conditions and peripheral neuropathies. Although I primarily see follow-up patients, I do have the opportunity to see new patients, primarily those with peripheral neuropathies. I am seeing patients five half days a week. I wear an additional hat as nurse manager for the Outpatient Neurology APPs. We are a large academic center, and we are a PPMD care center for care of patients with Duchenne muscular dystrophy. We are a center of excellence through Cure SMA for care of the patients with spinal muscular atrophy. We're an MDA care center and a CMT care center. We practice most of our clinics with a multidisciplinary approach. We have both physician and advanced practice providers, nurses, social work, physical therapy, occupational therapy, orthotics, social work, speech therapy, and palliative care. Although not all of the disciplines attend every single clinic, there usually is a combination in most. And like I said, we care for patients across the lifespan. What I like most and find most unique in my role is that I have the opportunity to care for patients for a long time, and sometimes I'm seeing multiple generations of families. And I really enjoy the multidisciplinary approach and team-based care approach. I wanna thank Maggie for the opportunity to give my input as to how APPs practice in the neuromuscular world. Something I really admire about Deb's role is her opportunity to treat longitudinally. Something that I particularly struggle with is that transition from pediatric care into my clinic in the adult world. And so having that straight continuity of care sounds very, very nice. Next we have Deb O'Reilly. She is a PA who works at the University of Colorado Neurosciences Center. She's been in her current role for 12 years where she is active in teaching and research in addition to her clinical duties. I'm Deb O'Reilly. I'm a physician assistant and senior instructor with the University of Colorado School of Medicine Neuromuscular Section. I've been with the group for the previous 12 years. Prior to that, I was in internal medicine private practice for many years, at which point I wanted to make a transition to academic medicine. In this current role, I have the opportunity to see return patients across the spectrum of neuromuscular disease, including the hereditary and acquired neuropathies, myopathies, and neuromuscular junction disorders. I am quite autonomous in my role and I attribute that to the length of time I've been in this position, as well as the amazing support I get from my physician colleagues. My physician colleagues are generally very available to provide education, consultation, and general support. In this role, I've also been able to have opportunities for involvement in clinical research, as well as teaching at the bedside and in the classroom. There've also been administrative opportunities, including developing a neurology APP fellowship within the department. Generally, I have really enjoyed my time in this role because I feel like it offers continual growth and an opportunity for other aspects of medicine. And I feel like I learn something new every day. So I completely agree with Deb here. I think it is really great to see that growth of a career outside of clinical responsibilities and seeing professional development in the field. Finally, we have Holly Cannon, who is an APRN working in the Department of Neurology at Vanderbilt University Medical Center. She's worked in the neuromuscular team since 2019, but has several years of experience in neurosurgery, ambulatory, and critical care. This is a testimonial of Holly talking about her onboarding experience. After I graduated as a nurse practitioner, I was so excited when I got a job in a neuromuscular clinic. However, I also felt this was very daunting due to my limited exposure in my graduate studies. When I started seeing patients I often left the room wondering if I did the right thing or said the right thing and this led to my imposter syndrome. When I discussed this with one of my attendings they helped guide my studies, started meeting with me weekly and even reviewed my study notes that I had created. With all of these changes I soon became confident in my abilities and my imposter syndrome soon disappeared. Even though I had minimal training in school the training that I received on the job is what led me to be successful in this role. I really appreciate Holly's candor here talking about imposter syndrome because that is something that is not unfamiliar to myself as well as probably many of us kind of entering a subspecialty space that has a very historically predominantly physician held role. So that said it sounds like having mentors and colleagues to guide our learning and clinical practice has been very instrumental in helping us feel confident. So that's that's all I have for today. You know I think most importantly today our big news is that the AANEM has now approved a position statement for the utilization of APPs and neuromuscular practice. I encourage everyone to take a look at it you know we really took a lot of time and care to to devise it and and really make it the best that we can be for for our own professional development. I'm gonna turn things over to Dr. Chris Doty now to talk about onboarding. Thank you. All right well good afternoon to everyone. As Maggie said my name is Dr. Chris Doty. I am a neuromuscular neurologist at the Brigham and Women's Hospital in Boston. My academic focus is largely in medical education. I run our neuromuscular fellowship program. I also teach the residents quite a bit and so my interest in this area kind of came about when our department several years ago hired a large bolus of outpatient neurology APPs and I was just sort of struck by the difference in how things worked for them. You know in contrast to our residency and fellowship experiences people finish PA or NP school and then just start a job and there they are. And from you know someone that's interested in education I thought there was a real opportunity there to do better for people that are entering our field of neurology at large and neuromuscular in particular for you know today's interest. So over the next 20 minutes what we're going to talk about is you know how do we take someone that has really had little exposure to neuromuscular in their traditional school experience and get them to that really advanced you know truly specialist place that we heard about from our three testimonials earlier and for Maggie of course as well. You know what does it take to really craft a process that gets people where they want to be. We'll start off with my financial disclosures which you can see there. So we're going to start off with a bit of a thought exercise. This may actually be real life for some of you but if not I want you to imagine that you're working in a neuromuscular group practice that's gotten quite busy due to an increase in the demand for neuromuscular care in your community. There's three neuromuscular trained physicians in your group and there's a demand for you to take on new patients but obviously you still need to take care of your established patients so the group is a little bit stuck. So the proposed solution is to go ahead and hire an advanced practice provider to help out and the practice manager comes up with a proposal where the APP will have six sessions per week. The APP will focus on seeing routine follow-ups so that the physicians in the group can take on more new patients and then in addition to that each clinical session they have they'd see one new patient slot restricted to only straightforward referrals from PCPs directly. So the question is what do we think of this model? You know from the standpoint of the practice this sounds great. It solves some problems, it gets a lot of patients in and out, sounds like a perfect model right? But let's think about this from the perspective of the APP and you know what are some of the things we don't know about the situation that would be helpful. So you know for example what's the background of this APP that we're gonna bring in and hire? Have they ever seen neuromuscular conditions before? You know what was their exposure in school or any prior jobs that they've had? That's really gonna influence how ready they are to actually take on this model that we've set forth for them. And you know certainly it sounds you know easy in practice to focus on established patients. You know the physicians in the group certainly could you know establish a plan of care, maybe even put contingencies in a note so that sort of no matter what's happening with the patient the APP has some guide. But we all know that's not how real clinical practice works right? A patient with myasthenia for example that appears really stable and has a nice prescribed prednisone taper for the next year, you know what happens if that patient has an exacerbation? Do we know if this APP has sufficient neurologic exam skills for example to actually recognize you know signs of worsening? Are they familiar with some of the new treatment options that are out there for myasthenia which you know likely are not covered in a preclinical school setting right? So a lot of open questions before we can make a practice idea like this actually work. And I think when we think about bringing APPs into practice this is really a consistent barrier right? That physicians that have never worked with an APP before are often not very familiar with what the starting knowledge base of an APP fresh out of school actually is. So let's dig into this a little bit. This is an area that I've had a little bit of an academic focus on and I'll sort of share some of the data we've collected in this space. So what you can see here is some work we published a couple years ago. This was Maggie and myself, a colleague of ours Dan Harrison did the lion's share of this work. He's at Boston Medical Center and we surveyed every PA degree program in the United States to try to understand what is the extent of neurology education nationwide in these PA programs. And we're going to start off with preclinical training. You can see here that things actually look quite good right? Across the board very high exposure to the core concepts of neurologic practice like neurodisease, neuroanatomy, things like that. Neuroradiology and pathology maybe not quite as universal but I think that's probably the case for medical school as well. So not much to say there. We recently basically did the same project for NP programs nationwide. This has not yet been published but I can show the data since it is complete. Very similar trends here across neuro exam, neurodisease, neuroanatomy. You can see that neuroradiology and neuropathology are a little less well represented but we added this question to the NP project about lesion localization which you know most neurologists would really consider to be a very foundational area of clinical practice. And this is really an idea that's introduced in the vast minority of NP you know at least preclinical coursework. And so a potential gap for someone entering practice. So if we switch gears to the clinical sphere, so people doing their rotations, you know their clerkships, whatever they may be, you can see a very different picture. So this is again is for the PA degree programs and the question was worded basically. We asked each individual program in an average year what percentage of your graduates left with some clinical neurology exposure. So some type of you know clerkship, preceptorship, what have you. And the vast majority of them said that one to twenty percent of their graduates did a neurorotation basically. Ten percent of programs said zero, meaning they actually had no mechanism by which to give their graduates a clinical experience in neurology. If we look at the NP programs, very similar story. Again that sort of one to twenty percent number holds. So really it's going to be you know the PA and NP students who have a specific interest in neuro and have the motivation to sort of go seek that opportunity out. It's certainly not routine. So I want to be clear you know I don't mean to show you this data to say that an APP you know can't or shouldn't work in neuromuscular or neurology right. This would basically be saying the same thing as saying you know like a fourth year med student shouldn't be working in neuromuscular right. It just means that there's a gap here. We need to help educate people that are entering our field to make up for some of the things that they do not routinely get in their degree program right. And just one final word right in case you know this idea of education and providing sort of excellent clinical care is not enough. I also want to say that paying attention to training really has a financial incentive as well. We know consistently across the board that when we ask APPs who leave jobs and are dissatisfied poor onboarding and preparation for the job is a driver of that. You know estimates would suggest that it costs about a quarter million dollars to a practice to replace a PA or an NP who has left. So paying attention to onboarding and training really does pay dividends to promote retention, keep people happy, keep people around. All right so let's start to think about what a model would look like to help build experience and education in neuromuscular. So you know for the physicians in the room this is the model we're used to right. The residency training model where we have a very predictable amount of time to have a captive audience and plan out the whole scope of training. So with that luxury we can basically start by building a nice foundation in general neurology. So neuro exam, seeing a little bit of everything, getting your feet under, you're getting comfortable. And then with time we build in those subspecialty experiences and it's really only at the very end when people pursue their fellowship that they actually make a career choice and sort of focus on a subspecialty. If you think about a practice hiring an APP out of school we essentially flip the entire paradigm around right. This practice is hiring an APP because they have a clinical need today. They do not have three years to sit around and do a residency program. And this APP needs to fill a very specific often very very niche clinical need you know as soon as possible. And so our models for thinking about training from our own experience can't really hold right. This has to look different than what we're used to. And for this to work at all I think there's a couple things that are worth saying. First of all to really meet this very specific need we need to be crystal clear about what it is we're actually expecting right. You know the APP can't just intuit what the need is and what we expect. I think being as specific as possible about the role that we intend the APP to fill in the practice is really helpful for actually devising the plan for getting there. I think on the back end though it's equally important to remember the rest of this pyramid right. Even if an APP has sort of entered practice they're successfully seeing a bunch of neuropathy patients everything's seeming great. We can't forget that over time it's going to benefit everyone to expand outward expand that comfort zone start to get some of those other foundational areas of neurology under their belt so that when surprises come up in clinic you know they are prepared for those as well. So what I would like to propose is the following five step plan for devising an onboarding plan. Now you don't have to necessarily do every last thing I tell you in your own practice but the goal is to sort of brainstorm around some ways to make this a little bit more preplanned a little bit more structured and really sort of get to that end stage that you heard about that is possible. You know this is not exactly easy right. This is not going to be something that you can just sort of do on the fly but that really truly is the point. You know for this to go well I think it is essential that some pre-work goes in and a plan is in place before you know hiring an APP. I will say as we sort of go through these steps all of this is kind of under the assumption that you're hiring someone that does not have neuromuscular experience obviously someone that's been working in another clinic is this is gonna be a very different situation. So let's go step by step. Step one you know what is the desired role for this APP. Really what this step is meant to be is a brainstorming exercise well in advance ideally even before you put a job description out there. What does this practice need and what do you want the APP to do to fill that need. And so a few questions to think about would include you know are you going to expect the APP to see new patient consultations. I think this is a big branch point in terms of the level of sort of autonomy and independence that an APP would have and it's even more detailed than that right. You know you need to decide if you're going to be seeing new patients are these going to be shared visits are they going to be independent visits. If it's a mix who's going to decide you know which is shared and which isn't. For those independent visits that they may or may not see will the physician be involved in some way later to kind of go through the cases. I think these are all really important things to work out and have be very clear as much as possible. We can get even more specific right. So if the APP will see new consultations is anything fair game or are we going to restrict that at all right. So for example if someone has seen a neuromuscular physician elsewhere or perhaps a general neurologist and they're looking for like you know sort of another angle another bit of expertise. Is that something that the APP would or would not see or there are certain diagnoses especially early on that we might restrict. So like a really advanced genetics case for example in the first year of practice. All right. And then you know with follow ups kind of the same idea. Are these all going to be independent or some of them might be shared based on you know the diagnosis or the complexity in some way. If there's urgent visits. So again like that my static who's calling in with a flare. Is that something that maybe the APP would do in the practice because they have some slots blocked in their clinic or would the physician handle that. And of course you know we all know that a lot of clinical practice happens outside of these clinic visits. So what happens in between. You know let's say the provider has ordered an MRI for some cranial nerve symptoms and unexpectedly the patient has a meningioma. Will the physician expect to kind of be notified about that and sort of chat about a plan before the APP acts and calls the patients or you know that be an independent decision. And again this sort of plays into this idea of how you're going to build out the rest of the training. You know if you are a physician that's sitting there thinking that I do not want to be notified every time an MRI shows an incidental finding then you need to focus on everything outside of neuromuscular as well. Right. That sort of general neurology base that will come later is equally important to some of the neuromuscular specifics that you're going to start with. So once we have that idea in place we kind of know what the end goal is. We need to figure out how we're going to get there. And I think there's sort of two parts to this. So the first part is a clinical volume ramp up. There is no kind of like set strategy here. Obviously it's going to really depend on your own practice and your own desires. But I think it's helpful to see a really concrete example. So this is not a neurology example. This is from primary care. This is out of the kind of PA educational literature. But what I like here is just how concrete it is. So as you can see from the table here sorry it specifies how many patients the APP will see each of the weeks during their first year or so. How many sessions they'll have like a clinical mentor in the clinic with them. And then most importantly I think how the mentors or the supervising physician or maybe like a more senior APP how their own clinical schedule is going to be reduced to actually make that happen. Right. If someone's going to be literally in clinic with them seeing a bunch of shared visits like giving them feedback in real time you can't do that with a full clinical schedule of your own. That's not realistic. And so I think being very explicit from the practice standpoint that we're going to support this by actually giving the preceptor time to do this is equally important. And I think as you're thinking about this sort of volume ramp up thinking about some of those key decision points like you know when in this process might independent visits start or when might new patient visits starts giving giving a goal to your APP I think can be really helpful in that regard to help speed this along as fast as possible. I will say I think trying your best to minimize the use of shadowing as an educational tool is helpful. I don't think that's a really effective way to get people kind of independent quickly. I think the better strategy would be you actually shadowing the APP. So seeing how they're doing themselves. I think that gives you a much better sense of their exam skills you know what what their knowledge gaps are and can kind of you know give direct feedback that allows independence to come sooner. I think realistically an onboarding period is going to be anywhere from 3 to 12 months and probably realistically on the longer end of that spectrum. You know this is a very subspecialized field that we all do and there's a lot to learn right. And so there's not really a way to speed this up and do it. Well we need to give an honest amount of time to sort of get people where they need to be to kind of emphasize this point. I want to share some data that we actually sort of collected at our own local institution. We followed the APPs in our neurology group over their first year of practice in terms of their own sort of self efficacy around very core you know medical concepts. And I want to focus on this sort of month 3 area. An area where we would sort of naturally think you know okay maybe people are kind of like you know more independent. But at this point you can see that APPs are relatively you know confident in like history skills exam skills but still feeling quite neutral when it comes to things like building out a differential you know sort of guiding a workup you know knowing the sort of the next steps in disease management. You know certainly they are not all the way to an independent practice state at that time. So it really just underscores the amount of time necessary I think to kind of plan ahead for this for this training. So this is maybe the most advanced step I will share with you but I think if you can pull it off it really can be quite powerful and helpful, alongside this idea of a clinical volume ramp-up, it's useful to think about a complexity ramp-up as well. And what I mean by that is, instead of just sort of opening all the gates of neuromuscular to your APP at once, you know, might it be more useful to kind of sort of restrict and feed them very specific types of patients in a predictable fashion? The idea here is, if you're thinking about sort of, you know, how you might learn and study best, being able to really focus on one area of neuromuscular in an intensive way before kind of moving on would allow someone to sort of build that independence and become confident in that skill set a lot faster. And again, the idea is, if you can sort of get to that point for one disease group, now all of a sudden an APP can very confidently, independently see patients in that group, have some clinical productivity for the group, while still training and learning more after that. And so I think a thoughtful way to go about doing this would be thinking about your practice at large, you know, what's the biggest chunk of your patient panel? You know, if you have a lot of neuropathy patients, for example, you know, maybe having the APP focus on that area first would be the most impactful thing for the practice to sort of get to independence, you know, most quickly. Of course, it never hurts to actually ask the APP what they want. Maybe they have prior experience with muscular dystrophy from like school or family, you know, they're really motivated to learn about that area first. Working together with the APP, I think you can sort of come up with an idea of finding that one high-impact area. So once you have an idea of what this ramp-up might look like, this is where I think the educational piece comes in. It's really intuitive at that point to basically pair educational activities that fit with what they're doing clinically. Month one, obviously, they're just sort of getting their feet under them, focusing on really foundational things like the history and exam is going to be pretty universal. But again, put in a plug here for things that can basically be productive and make money for the practice during this stretch, right? So doing something very straightforward like training the APP on skin punch biopsies for small fiber, now all of a sudden they can do that on their own, you know, you free up time for the other physicians, they can have a little bit of financial productivity as they keep going through their training, right? So if we have this practice that has a lot of neuropathy, maybe months two and three, a lot of the follow-ups that are scheduled will be sort of straightforward neuropathy patients, very straightforward then for the APP to spend their studying time on that topic. Months four and five, we'll move on and sort of build in some myasthenia. And then finally, month six, we'll start to see some new neuropathy referrals and start to introduce some things like, you know, how do I make sense of this EMG report? What are the most high-yield lab tests to send in neuropathy? And I think it's really hard to sort of build out this educational plan without having a sense of what the clinical practice will look like, you know, alongside of it. All right, so the key question though is like how are we actually going to do this education? You know, what does an APP need to learn? And so what our own program at the Brigham includes is pretty multifaceted. So we have some videos from an institutional library that we kind of suggest on a weekly basis for the APPs. There's some dedicated readings. There's a meeting with the supervising physician once a week for key topic discussions, and then kind of a logistical training checklist. We're an academic center, so we're very advantaged in that we have like, you know, pre-recorded lectures. We have a lot of people around. We have trainees around. Fully appreciate that in private practice, this can be much more challenging. But there are, you know, there's a lot of help out there basically. So both the AAN and the AANEM do have resources specifically tailored to this idea of APP education. You can see a list of some of the things that are out there as well. All right, so that brings us to our final step, step five, and that's actually trying to figure out how the APP is doing in real time, tracking their progress. The most straightforward option I think that's available to you is a combination of chart review and some patient logs. So most practices when, you know, an APP is starting would do something like, you know, review all the charts for independent new patients and some percentage of the established patients just to sort of get a sense of how the APP is practicing and, you know, what their patterns are. This idea of patient logs, what I mean by that is sort of figuring out prospectively like how much experience you want your APP to have before they transition to that more independent state. So a very practical approach to this would be, you know, thinking about maybe the five most common diagnoses you see in your own neuromuscular practice and for each of them like sort of think ahead. Okay, for idiopathic neuropathy, I think maybe if the APP can see five of those in a shared visit, I'd be fine with them kind of going independent with more indirect supervision. But maybe like a, you know, suspected muscular dystrophy case with like needing to send out genetics, maybe I want like 15 of those before they're ready to go independent. And again, it's just very clear what's expected in advance for everyone involved. All right, well, hopefully that overview is helpful. Again, this is not meant to be like prescriptive, you need to do every last one of these things. But I think it can at least give you a realistic look about, you know, what it takes to be thoughtful about this and take someone that is truly a novice in our field to being, you know, a very helpful, productive member of the team in a respectable amount of time. So thanks so much for your time and attention. And I will turn over the mic. Good afternoon. I'm Darlene Sawicki. I am a nurse practitioner at Mass General Hospital and the ALS Clinic. I am also the director of advanced practice providers for Mass General. So I oversee scope and practice for about 1,400 APPs at Mass General. And I have been in the ALS Clinic now for 20 years, 14 of those are in as a nurse practitioner. Nursing was a second career for me. I was actually in clinical research prior to that. And I became a nurse because of the nurses at Mass General. And I became a nurse practitioner because of the physicians that I work with in the ALS Clinic. So I went to Boston College where I got my nurse practitioner in adult gero. So my boards are from age 13 and up. So I'm excited today to talk to you about how our clinic works in the ALS Clinic at Mass General. I have nothing to disclose, but I'm always looking for some disclosures. So if you know of anything, let me know. So this is our multidisciplinary care. As you can see here, we're fortunate at Mass General that we have a large multidisciplinary center. We have a primary model where the patient has a primary neurologist, a primary APP, and a primary RN. That team is very tight and it is highly functioning. So we have PT. We have access to OT, access to RT. We have SLP in our clinic. We have community resources that we partner with. We have palliative care. We have dual board certified physicians that we work with that are in neurology and palliative care as well. We have a pulmonologist that we work with, et cetera. You can see if you have worked with ALS patients, you know that it really does take all of these people to care for the patient. So how do we do this? So the initial diagnosis at our clinic in particular, it is always done by the neurologist. If a patient has been diagnosed elsewhere and they are looking to transfer their care to Mass General, they can see an APP for their first time visit. But if there is not a diagnosis of ALS, it is done by a neurologist. What we typically do is we have the patient come back within one week to a month to meet the APP. I usually sit with the patient and ask them, you know, do you understand what Dr. So-and-so told you? Do you have any questions about the medications? And then I always review the red flags to go over that we want to hear about right away. You know, changes in breathing, loss of more than five pounds and keeping it off for two weeks, you know, falls, et cetera. And review how do you page us if there is an emergency. Review the medication, you know, safety parameters. And then I also talk to them about, you know, how do they want to be cared for? There is a spectrum with this. Some patients want everything. Some, you know, say, Darlene, stop your lips flapping, let me go home and be with my loved ones. So I look at it as my job is to bring that patient to health in the absence of a cure. Most of our physicians in our clinic are also researchers. So they are trying to find the cure, stop the disease or slow it. And now looking at reversing it in some of the genetic mutations. We also have an NP that goes out to the house for house call program. This is great. They can exchange G-tubes. They can see if something is going on, if there is anything in the home that needs to be evaluated quickly. And the APPs have dedicated time on their schedules for urgent visits. We do all the HNPs for G-tubes. And we do the vast majority, probably 90% of the goals of care discussions. I'm also pursuing a Ph.D. in health education on serious illness conversations and how do we teach this. So this is a passion of mine and a strength of mine that I am able to bring to the clinic. So here's just some do's and don'ts. I give this slide to all of the physicians at Mass General when I meet with them and they're thinking about hiring an APP. The do's. You've heard this from the previous presenters. We are trained as generalists. My clinical rotations when I was at Boston College for my NP were in neurology. And just a sidebar, I remember when my clinical rotations, I won't say the names of the physicians, but quite often I was trained how to perform a neuro exam by one physician, I would go to my next rotation and a neurologist would ask me, who taught you how to do that exam? And I'd be scared to say who taught it to me. And it became a joke because the next time I went, I corrected my exam, went on from the next physician who taught me how to do that, and the next one, ugh, these NPs don't know how to do neuro exams. Who taught you how to do that? And you're just sitting there like, he did, Chris did, no, it wasn't him. But this is one of the things that we run into. So one of the things I tell the physicians is please mentor. I've stayed in ALS as long as I have because of the patients and because of the team there and because of the support I've had from the physicians there and all of my colleagues. Most of us have been there for over 10 years as APPs. You also want to introduce the APP to the patient. There should be no surprises to the patient when they're going to see the APP. So up front, our physicians tell them, you're going to see me, then you're going to see Darlene. Then you're going to see me. Darlene has urgent visits. She's able to get you in there. She's fantastic at symptom management. The physicians will tell you, I'm a lot better at symptom management than they are. But I am not going to diagnose ALS. And lean into the strengths. My strength is having the serious illness conversations. So the physicians, I've become known at Mass General, I'm called to the floors when they have goals of care. I'm called to the ED. I'm called to all areas of our hospital where there's an ALS patient or PLS patient to have these discussions. The physicians know and they lean into that. And it actually builds a strong collaboration on there. And ensure the APP is properly resourced. This is a big one. So if the physician has somebody to schedule their clinic and they have a nurse to help with, you know, triaging, phone calls, et cetera, and the APP is expected to have full clinic schedules, they need just the same amount of resources. They need somebody to schedule them. And the schedulers need to be helped along. So in case somebody calls up to say, I'd like to have an appointment with Dr. Jones, the scheduler is not saying things like, Dr. Jones isn't free, but you can see the NP. You know, that doesn't really build a lot of confidence in there. You know, we teach our schedulers to let them know, this sounds really important. Darlene's going to be able to see you tomorrow. And don't worry, Darlene and Dr. Jones speak all the time. There's no loss in continuity of care. The don'ts. Don't refer to a nurse or an APP as your APP or NP or as a mid-level provider. Mid-level's an old, outdated term, and it doesn't invoke confidence for your patients. And the term my APP, my nurse, you know, they're not indentured servants. They can vote and buy property. They are, you know, work for the system typically. So it just doesn't invoke that confidence for the patient. Do not bait and switch your clinics. This happens. Things happen. You know, physicians, sometimes they're called out or whatever. They're on service. They couldn't get over. Whatever it is. If somebody is on your schedule and you need to switch it to the APP, have the scheduler call and let them know. You are being switched to Darlene. We're very sorry. Dr. Sokovich was called away. This is the physician I work with. That was called away and she's not able to see you, but we assure you that Darlene is in real-time communication with Dr. Sokovich. Do not use them as scribes or as administrative task managers. They will not stay with you. I have stayed in ALS for 20 years now because I have been supported and worked at the top of my scope at all times. Don't assume competencies. We just heard about this. It is really important. Don't assume competencies. Ask them, how do you feel with this? Watch them. You know, this is important. Sometimes people are nervous to say I'm not comfortable in my neuro exam or I'm not comfortable reading an EMG, but if you create an environment where that trust works both ways, loyalty will as well. Now we do not bill I-2. I haven't asked it here because we do not do that. I guarantee the vast majority of people who are billing I-2 are probably not billing appropriately. It is a very strict criteria that allows you to legally bill I-2, and the vast majority of visits do not qualify for that, but again, that's to be taken up with your own institution. I'm happy to talk to anybody to let you know what some of those requirements are, but we do not. We do independent billing only. Here's some spotlight on some of what the ALS APPs are doing and that these are potentials. Professional experts in serious illness conversation. That's me. ALS symptom management specialists. We have APPs running LP clinics, CalSOTI clinics, and soon to be we're sending somebody back to school to be dual certified as a nurse practitioner, both in adult gero and in mental health, so that way they can now start caring for our patients for mental health. There are also sub-investigators on a lot of the clinical research trials, and they're running the clinical research trials, so that way our PIs can actually focus on the science and looking for additional research studies and writing grants to get us the additional research studies. These are just some of the things that our APPs are doing. Some key takeaways here. Loyalty works both ways. The APPs will be very loyal to you because they have seen areas worked in clinical or in working that have not been supportive or have dropped them in the deep end and just asked them to swim. Language is important. When working introducing an APP to the patients, it's important the language that you use. You set the tone. You set the tone for the patient to interact with the APP, as well as the APP to interact with the patient. It would be just as disrespectful if the APP were to say something negative about a physician on there. So APPs can be true partners in this, and we already just said don't assume the competencies. They welcome the mentorship. I am still being mentored by my physician colleagues. There's some physician colleagues that I've actually grown up with over time in our clinic. We have a battle right now. He thinks he's Batman and I'm Robin, but I know I'm Batman and he's Robin. We are now incorporated into the fellows rotation as well. I have to say it's so fun because the fellows come in and they get a different perspective of how we work in the clinic, what we do in the clinic, and they walk away every time saying it's amazing to see it through your eyes. They will work with APPs in their career, so it's important to expose them to this early on. An experienced APP can help train new PIs if they're in research, new APPs, new physicians that come on, fellows. They can be there. They can partner with you. Because APPs are not disease specialists, we are very good generalists in a lot of things. I'm the go-to person if there's cellulitis in the clinic. I'm the go-to person if somebody has a yeast infection because their PCP no longer sees the patient or they physically can't enter the PCP's office because of ALS. Sometimes we become the de facto PCP in some areas, and that tends to be me. I'm the closest to that. The physicians I work with, it's been a very long time since they've done general internal medicine. I say lean into the strengths of the APPs, and you can actually grow a very successful practice where your APPs will stay for, I said your APPs, look at me, APPs will stay for quite a while. So here is my email address. You're always welcome to reach out to me. I do wear two hats at the hospital, so do allow for a delay, but I thank you for your time. I'm grateful to these folks for inviting me to come speak with all of you. Thank you. Well, last up here, while my colleagues gave you all the meat and potatoes of how to make some change and incorporate APPs into your practice, I'm going to add a little bit of that sauce on board, a little of that spice, and talk about some barriers and burnout and things that happen when we don't have a team approach. So I'm going to be focusing on those particular areas. These are my financial disclosures. The objectives of what we'll be talking about to wrap this up is improve communication and referral process from general neurology to neuromuscular specialists, implement a team-based neuromuscular approach involving APPs to enhance clinical outcomes, improve patient experience, and reduce wait times, and lastly, utilize a team-based approach with APPs to reduce provider burnout. So a little bit about my story. My name is Dina Rodney. I'm a nurse practitioner. I am out of central Florida. I have been in my private practice for 15 years, and I've stayed at the same practice for many of the reasons that we have already talked about today, support, education, and modeling. But I didn't start off, actually, as a nurse. I actually have a background and certification in sports medicine and psychology. And through that venture, I became a tech in the hospital, and these nurses encouraged me to move forward to be a nurse practitioner. I then became an educator at the hospital for a neurosurge, neuromedical, and neuro-ICU group, and then advanced that over to generalized education for a system hospital. Once I graduated with my nurse practitioner, the neurologist that I had worked with at bedside said, let's give Dina a chance. And I started off with their practice, and I thought, I might stay here for one or maybe two years and, like many, move on. Fast forward, 15 years later, I'm still with that practice. So some of the takeaways and why I explain that is it's nice to know who's up here talking to you, but also really what I want to encourage and empower as we look at this model and we grow together as a team is it took me a little time to find my love in neurology and neuromuscular. So please, takeaways. Be patient with your time when you're incorporating your APPs. Be very generous with your experience. Each patient is unique, and we don't all get to have that opportunity. And be very supportive of that learning and education model. So moving forward and implementing a team-based neuromuscular approach that includes APPs, our main goal would look at the introduction of APPs to typical standard and treatment pathways for common presentations to more complex diagnoses to increase APP knowledge upon entering the practice. This builds off a little bit of the model that we talked about a little bit earlier in part two. The outcomes, though, are to help facilitate delivery of consistent care from APPs to all levels of experience, which will improve clinical outcome. This will take away kind of that experience of the patient walking in saying, why am I seeing the APP? I thought if I had an abnormal exam, I would be seeing the physician. Not always the case. We want to build that experience and that knowledge and encourage and collaborate so that we are building upon that. And then the second part is making delivery of care more efficient, which will minimize patients' wait times for appointments and ordering diagnostic tests, receiving their test results, which therefore would then reduce anxiety, and establishing a treatment plan. What is the current utilization of APPs out there in the community? In large medical groups, about 45% of them utilize APPs. In major healthcare systems, only about 34% are utilized. And in small private practices, only about 25% are utilized. This brings one of the major issues that we are facing today and happens to be a pretty hot topic even in AANEM is wait times with our neurologists and our neuromuscular specialists. So that brings us to generally, two is always better than one. And sometimes we have a larger group if you're in a larger institution. So increasing APP availability also works into the patient journey, which includes increasing communication, which then decreases some of that daunting task that we typically have outside of what we like to do. So the phone calls, the portal, the excessive emails that we're needing to answer all the time. So having that communication, two is better than one, increases that, therefore increasing productivity for the patients, and of course, because it's a business, billable encounters. So let's talk about what's some of the problems that we're identifying that are out there. Definitely on the very top of that is the long wait times. We've seen this recurrently in our talk today about how long it takes to get into a neurologist and a neuromuscular specialist. But we haven't touched yet on provider burnout. And that provider burnout is very real, and it includes provider burnout with physicians, but also with APPs and even ancillary staff. It then leads to unsatisfied patients, and of course, we also have a big issue now, which is a wonderful thing. We're taking very good care of our patients, but we now have an aging population that's increasing our schedules and need for more healthcare providers that are out there. And so with the aging population, then of course comes the complexity of that patient load. So we would like to improve the patient experience, and looking at that first one is minimizing the wait times. Let me just highlight here in the bold is what this study looked at, which was done through AMN. And what that said was that they looked at 15 major metropolitan areas, and they looked at five different subspecialties. And the key finding reports that were average wait time in 2017 and 2024 continue to increase. The other thing that affects wait time, unfortunately, is the type of insurances that are offered. Now last year, data was conducted for the survey for the AANEM on how long wait times were in neuromuscular practice. I think that if I had a clicker in this room, it might be a little bit different in real time, but as you can see, it was about two to four months of a wait time. I'm not sure that that is across the board here. We had documented elsewhere that it might be close to six months, but depending if you're actually willing on seeing the APP versus the physician can actually change some of those wait times. So statistically, we don't have that data, but there are some patients who actually refuse to see the APP, even if it's part of a shared model, and they will work with that physician. And that's where that communication and the model needs to become more standardized. So how do we talk about that patient journey, and where does that new patient fit in? What model do we fit? This is not necessarily a one size fits all type of model. It can be a shared experience. It can be independent based on the type of practice you have and the experience of the APP, but that is something that you need to identify and hone in on your practice, including how you would identify diagnostic testing. Would it at first be the APP, or would it be the physician, and then who would that follow-up be with, utilizing the appropriate skills of all of our clinicians? So addressing physician burnout, in 2020, a publication from American Academy of Neurology AAN noted 40 states reported shortages of neurologists, 11% shortage of neurology care in 2012, and then there was an estimated increasing to 19% in 2025. This is not only limited to the U.S. This is actually a global issue. This decreases, unfortunately, patient's access, which degrades the patient's experience and their availability to get to medications, including wait times that they need to get medications approved through insurance, and it forces general neurologists to practice in subspecialties when they do not necessarily feel comfortable for this area. The drivers are too many patients, unhappy patients, and inappropriate use of resources for unnecessary referral or consults. So how do we work on extinguishing those flames and cutting down on that fire? In 2023, the publication from American Medical Association said that we're finally dropping down below 50% on the burnout rates, but statistically, we are just under there, but they finally got there. So in 2021, the burnout rates and dropout was 62.8%, 2022 was 53%, and then—I'm sorry, that's an error on there—in 2022, that should be 2023, was 48.2%. And the way that they looked at this and monitored it was by all the bullet points you'll see up there. It does reflect the trends in six key performance indicators, including job satisfaction, job stress, burnout, intent to leave the organization, feeling valued by an organization, and total hours spent per week on work-related endeavors. And then one-fourth reported not enough providers or support staff that were available. We do know we talked a little bit about what it took to recover from the loss of an APP from a practice, but statistically, what they're showing is $4.6 billion a year in providers leaving due to burnout and not having the appropriate team and collaboration that causes that. And this is largely due to excessive working hours or pushing too many patients in for a short period of time or needing to double book due to emergencies and not having support staff or APPs with them. So we talked about the cost of what it would be to replace an APP. To replace your physician when they don't have support to have the appropriate APP staff would be anywhere from $500,000 to $1 million a year, depending on their specialty. That's quite a heavy cost to have when we're looking to get these patients in, and patients should be the priority of care, including that wait time. So I put this slide up here again just because, just a quick raise of hands. We're talking about goals here. We're talking about ways we can change and improve our healthcare. So I'm just curious, out of everybody in this room, the wait time to get in for new neuromuscular patients over for two to four months, close to six months, would be so over half the room. So the good news is we are moving in the right direction. It's just taking a little bit of time to get there. 2020 publication from the American Academy of Neurology did talk about burnout, but they updated their statement in 2022 verifying that there was an increase in APP in neurology and that they were supporting that, and that they also stated that the increase of positions and jobs in neurology also gave improved access to care, increased efficacy and efficiency, enhances quality of care, and they further noted the goals may reduce the need of emergency care. So being able to get to these patients quicker on time. How do we have job satisfaction and retention? I often get asked the question, what can we do to advance APPs? And so what we see here is a question was asked in 2023 and a survey went out asking, are you satisfied with your current APP physician working relation in neuromuscular? And 78% said yes, which was wonderful. But what you could see highlight here is factors contributing to the success of the retention of the APPs, and on the flip side, the factors limiting retention APPs in neuromuscular. So just to highlight a little bit of this for you, in the first line, in the intra-practice partnership, what we had was they had great support, open communication, good working relations, collaboration, having people they could bounce questions off of, basically. Physicians as mentors, having resources there. But the factors that limited it was the lack of physician support. And that's probably not because the physicians did not want to support them. They were not aware of the education that they actually needed. So we're trying to kind of change that culture to help that autonomy and that change of position of the APP so that the physician is able to give that support that they need. And then we looked at the challenges in autonomy, per se. And so the factors of contributing, we have that making sure APPs feel valued, making sure that you're calling your APP by the right name or saying, we don't have an appointment with the physician. We can fit you in with the nurse practitioner, making them feel valued, but not emphasizing on the other side, not enough training, lack of adequate training. These are things that within your clinic need to be taken care of before they work with these patients. I do also want to talk a little bit about the elephant in the room. It's very interesting when we talk about the professional, social, and community interactions that we have. If you see on the side of factors contributing to the success of the retention, it's blank. But if you look at what they had talked about with factors limiting retention of APPs, one statement is there very clearly, and that was, unfortunately, disrespect from the patients. It is a very challenging culture for APPs out there, despite the amount of education and work that's continued to do because of mislabeling and not understanding what APPs values are and not letting them work to their ability and to the top of their license. Overall, in general, the professional growth was very important. APPs continue to want education and thrive, and they also required the appropriate time to do so. Job satisfaction and retention, there is limited data in the literature regarding APP satisfaction and retention. If you look on the one side to start off the column of PAs maintain a very high level of job career, and then flipping it over right next to it are the MP satisfaction with their work environment. A few of the highlights that I want to bring out here is that overall job satisfaction on both sides for the PA and the MP is that they really wanted a community, and they really wanted support, and they really wanted education. Very important to get that. It's not thought that it's a stop at schooling. We want that education, we want that experience, and we respect your experience as physicians to get us to where we need to be. And then in regards to job satisfaction, it was proven that most PAs and MPs actually found a high level of job satisfaction, and many do not intend to leave their practice. So how do we overcome some of the barriers to implementing a team-based neuromuscular approach? Well, very interesting. Healthcare culture does not universally embrace APPs, and I think that part of that is not understanding exactly the difference between APPs when we talk about MPs or PAs, or even the level of education. What makes it different for a nurse practitioner to have a master's versus a doctorate, or what education did they come from before? They need to use standardized pathways to help with that care. I will bring out some interesting statistics just to reinforce how important that on-board training is, is that I looked up at a few certifying bodies. Unfortunately, interestingly, I couldn't find the one on nurse practitioner. But when you talk about neurology board questions and the percent that these specialties have, the PA national certifying exam said that they asked 7% of their board questions were neurology. But family medicine, and this is physician-related, was only 3%, and American Board of Internal Medicine was only 4% of neurology. So this is to bring home a little bit more of the didactic work is there, the foundation is there, but it's more of that clinical experience that needs to be created to avoid delaying any type of on-boarding. One more barrier actually is, who are we? What are we called? To be honest with you, I feel like our names are like the popular antioxidants. It's acai berry or blueberries this year, but we used to be called mid-levels. I kind of went through some of the names, and I think there's probably more out there. So APPs is a respectable term that is used right now for advanced provider. Just a week ago, I was asked to sign a paper that said MPP, and I actually don't even know what that stands for. I'm not sure, but they used it interchangeably. So now there's a new one out there. Defenders is another one that I particularly don't like. Nails on a chalkboard, mid-levels would be coming in on there. We're also called nurses. We're also called assistants, and we're also called doctors or physicians. We are not trying to be anything else other than what of our level of care and what of our certification says. It might be reasonable to start standardizing what we're called and identifying not so much for formality, but just to have an awareness that we have APRN, Dina, or PA, Maggie, and understanding that there's an awareness of this to help the community. So let's talk about a little bit more of when we don't integrate this team-based approach and not correcting the shortage. We start to fall further the other way. When we do not incorporate this team-based approach, we're starting to see more concierge medicine, which increases the cost of care for the patients in our healthcare system. It also still continues to lead to that cognitive fatigue and rapid provider burnout, inappropriate hospitalizations and shortage in hospital beds, inappropriate excessive referrals, influxes in the ER, and increased risk of mortality and morbidity. Concierge medicine, while I don't have any necessarily negative thoughts against it, what I can say primarily is it does not right now incorporate a team-based approach. It's solely one provider with only one availability. It does not allow access to the uninsured. It is a membership fee that can be very prohibitive. It limits encouraged corporations. Medicare and Tricare are not widely covered by them, and many rural areas or even suburbs may not have access to this luxury, if you will, and potentiating burnout with 24-7 access of care and mainly not incorporating the team approach. So when we look at that team approach coming in, we do have a trifecta, which does include the provider care team, access to care, and the patient. And this end model here really are just standardizations, tools, if you choose to use it. If you are part of a general neurology practice such as myself and utilize many outliers of neuromuscular specialists, ways that you can help your APP or even your practice start talking the same language and the same talk. So what we have here to minimize that list are referral templates to neuromuscular specialists that can be utilized. We put together two samples that your practice can use to help with identifying and slowing down that wait time of getting your patients into the neuromuscular practice. Therefore, if there is a long wait time, this might help the neuromuscular specialist scan this, give them the pertinent information a little bit quicker, and understand how to rule that work up or how to appropriately give that care to either the physician or the APP that might be seeing that patient. And so that would identify basically the patient's needs of the diverse groups, increase trust in that communication of the community that we're actually trying to reach out to specialists to get them that care. This patient journey of education, treatment, and referrals is not only education, treatment, and referrals for the patient. It is also a journey for the clinicians that are working with each individual patient and enhancing that. Even though the patient is going through their journey, we are going through it with them. And we need to have the education and the skills and the support to educate ourself to get them the best treatment also, and to be able to get them in the right place in the appropriate period of time with delaying wait times. These are other examples. If you could see here, that was brought from the Mayo Clinic and education. It's cited, it's quoted. That information and terminology that you can use, that there are resources out there for your APPs, there are also education models should you choose to use your APP as one of those education pieces. These are also templates of checklists. If you wanted to start making a checklist for your APPs when they come into the practice of kind of a series of what's going through. We do know when you do not have good support and good education in rare disease, you kind of tend to order everything in the kitchen sink at one period of time. And we do need to be a little bit more aware and a little bit more cautious of our dollars that we're using for insurance to be able to give whole care service to all of our patients. So helping understand that treatment workup. And so this kind of wraps it up for me, but I really do want to take a minute to say a special thanks to Jack Hyler, who's a medical student who initially worked on some of these templates as part of his medical student position that was in 2023. I do want to take a special thanks for industry for the education and support that you do provide to the APPs. And I do want to thank AANEM for your foundation, collaboration, and vision, including Dr. Kwon who gave us the foundation for our APP committee. And lastly, I really do want to thank all the amazing physicians that are here working to integrate this team-based approach and to give us your education and care, particularly my mentor, Dr. Issa. So I really do want to encourage you guys to be the change. Our medical care is changing. People are evolving every day, and we have the power to change this team approach. Thank you very much. So we have a few minutes for questions, and I'm going to be the person walking around with the mic if anybody has any questions. Hi there. I just had a question. I was the first APP in my practice, and they don't know how to support us with a nurse. And I was curious what ratios... You say ratios. Are you referring to how many patients we see a day, or, I'm sorry. You know I I don't I think it's different everywhere I could tell you if I'm answering this the correct way and then I'll open it up is that in our practice I see patients I have my own list every day and my follow-ups are every 30 minutes if that helps and my new patient times are an hour and every new patient is seen with the physician so we have that collaboration approach with that. As far as specifying exactly what you're asking. Yeah, in our particular institution we don't have, our neuromuscular division does not have a nurse. I think only a couple of our divisions in our department do, so most of that care coordination is through the APP or physician. It's like in the coordination of care in between. When we did have an APP, yes, that nurse or LPN. at. We had one LPN for like seven or eight providers at that time. But it's because she was part of our division, so she kind of took over, the support staff was helping her as well. But then we eventually had like two LPNs helping alternatively. But she was part of our division, if that's what you're asking, and then she helped with those. Yes, mostly. Yes, yes. And then, like for example, if my nurse practitioner is seeing patients as follow-ups, and then if a patient has a question, who answers that question, right? So the LPN would help take care of that and send it to that nurse practitioner, and she would, if she needs my help, she would. Thank you. Ratna Senka from UT San Antonio and I am an MD and I do work with APP and Who's Amazing without whom I will probably not exist so thank you. Just to just reiterate I think training is and coming up with an onboarding plan for them it's really important. We're also utilizing them for a lot of the prior authorizations and you know my chart messages that are complicated that the nursing staff are not able to do but it you know we get a lot of pushback from our administrators saying these are not really like up for the because we can't bill for them so we get a pushback on we don't want them to do that we want like the nursing staff to do it so is there been any kind of a suggestion on how you know there how we can overcome that that pushback from the administration if there we are utilizing them for my chart messages and prior authorizations. Thank you. On another note, I'm part of the American Autonomic Society, and in November, at the Autonomic Society meeting, we're organizing a two-hour directed class for the APPs for just basic autonomic disorders. So I think a workshop, something like that, would be helpful. So in this workshop for the autonomic disorders of the AS, we're going to have a virtual link, and I'll be sharing. Hopefully, I can share it broadly so people can even attend virtually just the two-hour session on Tuesday, November 5. I have a question because advanced practitioners are so vast and... model for them, like looking for the future, is that something that is down the road? No, because that was a great point with ENT, but what's the future like? Yeah, so the AANEM APP committee is committed to education directed towards APPs. At past meetings, we've had programming that's directed toward APP education, small group, and ask the experts sections, less so these big lectures, because we do have a pretty small percentage of APPs within the organization. We're hoping to create better outreach to kind of, hopefully at one point, do a formal needs assessment to kind of figure out what the education goals are for the APPs in the organization, and then not only target continuing education for APPs, but also devising onboarding plans and resources for physicians to use in training APPs, as well as for the more experienced APPs, professional development and continuing education. Come up and talk to us. We'd love to chat with you. We'd love to chat with anybody that's interested in joining our committee. We are small but mighty, so.

Advanced Practice Providers

neuromuscular practice

physician assistant

neuromuscular neurologist

PAs and NPs

scope of practice

onboarding process

training process

mentorship

physician burnout

patient care

collaboration

healthcare integration