A Collaborative Inpatient Model of Hematology Care

The integration of advanced practice providers (APPs) – physician assistants (PAs) and nurse practitioners (NPs) – into academic and private hematology and oncology practices is a decades-old and well-recognized model of care. APP integration began in the outpatient setting, where APPs help to deliver guideline-consistent cancer prevention and screening services and guideline-consistent therapy to cancer patients.¹

Now – due in part to the shortage of physicians training in hematology and oncology programs and coupled with the limitations on resident and fellow training hours – there is a growing opportunity for APPs in the United States to deliver that same quality care in the inpatient setting.

Inpatient APP care teams were developed to help ease increasing demand in hematology and oncology services. Models of integrative inpatient care teams differ depending on the institution; some integrate APPs into house-staff teams, while others use APPs in separate teams or even separate units altogether.^2,3

Below I'll describe the inpatient APP cancer care team at our center – along with the challenges and successes we have seen in the three years since developing our APP inpatient team.

Integrating APPs into Inpatient Cancer Care

At our center, Stanford Health Care, we developed an inpatient APP cancer care team separate from the house-staff teams. We work directly with an attending physician to provide care to an average of 15 acutely ill cancer patients. Later this year, we plan to increase that number to 20 patients. Our APP inpatient team consists of nine APPs who provide care seven days a week, 12 hours a day. During the 12 overnight hours, patient care is signed out to a hospital nocturnist team.

Approximately half of our team transitioned from careers as APP outpatient care providers, and half were hired as new APP graduates from acute care training programs. As we were a leading team in developing such a model, we have helped shape a path forward for the expanding role of inpatient APPs in other medical and surgical divisions at our center.

There is little doubt that the transition from a provider of outpatient cancer care to a provider of inpatient care for acutely ill cancer patients involves a steep learning curve. The transition can be daunting for many reasons, including knowledge deficits, high expectations, and the pressures of being responsible for time-sensitive, high-impact decisions in patients with complex medical diagnoses.

Transitioning and Training

Twenty-five years ago, Dreyfus and Dreyfus postulated a model of professional expertise that suggested that individuals progress through a series of five levels: novice, advanced beginner, competent, proficient, and expert.^4,5 That model has been adopted by both medicine and nursing to describe the acquisition of clinical skills.^6,7

The majority of APPs need 12 to 24 months to be competent in hematology/oncology.⁸ Some centers, including the MD Anderson Cancer Center at the University of Texas and The James Cancer Center at Ohio State University, now offer 12-month fellowship programs for APPs.^8-10

However, since fellowships are not available for most APPs, the American Society of Hematology (ASH) and The Association of Physician Assistants in Oncology (APAO) are collaborating with the Oncology Nursing Society (ONS) to create an online course for new APPs in hematology. Each topic in the course is authored by an expert hematology APP and a hematologist. The course is undergoing final editing and is expected to be released by the end of 2015 by ONS.

Another avenue for continued education is the newly launched Advanced Practitioner Society for Hematology and Oncology, a professional organization specifically for APPs that offers an annual conference, JADPRO Live, and publishes the Journal for Advanced Practitioners in Oncology.

At our center, development of an APP fellowship is one of our future goals. Until then, we require a three-month one-on-one preceptorship orientation that includes didactic teaching, procedural training, and advanced training in medical decision-making. This includes training with sub-specialty inpatient teams such as infectious disease and palliative care, as well as rotations in hematology and oncology clinics.

The orientation is broad-based to foster working relationships with consultants and to facilitate effective communication between the primary outpatient teams and the inpatient care team. At three to six months into orientation, the APP assumes a reduced patient load of three to four patients a day; this increases to a full patient load after completing the entire six-month orientation.

Successes and Challenges

To be sure, we have faced some challenges in implementing the inpatient APP team. There was a general lack of understanding by physicians about the required six-month-long orientation. Guidelines regarding an APP's patient load are not available. And, when our APP inpatient team was created, some referring physicians felt our team should not provide care to patients with complex medical diagnoses and conditions.

Over time, though, our team has gained the confidence of these physicians and now provides care for newly diagnosed acute leukemia patients, as well as for other cancer patients with complex diagnoses. We have reached a point where the acuity and breadth of diagnoses on the APP team parallels that of the house-staff hematology/oncology team.

An internal review of Stanford faculty and patients indicated that the advantages to having an APP inpatient team include: high patient satisfaction, effective coordination of care, timely communication with referring physicians, adherence to research protocols, improved symptom management, and decreased length of stay. These advantages can only be realized, though, with a commitment to providing a comprehensive orientation, ongoing mentorship, and a respect for collaborative practice.

Inpatient APP teams are increasingly prevalent in centers across the United States. As the demand for hematology-trained APPs continues to increase, our academic medical centers and professional organizations will have to continue to develop strategies to provide advanced training in hematology. Above all, the success of the APP team depends on the relationship between the attending physicians and the APPs and their shared commitment to professional development, mentoring, and team-based cancer care.

References

1. Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffing on outcomes in a medical ICU. 2011;139:1347-53.
2. D'Agostino R, Halpern NA. Acute care nurse practitioners in oncologic critical care: the Memorial Sloan-Kettering cancer center experience. Crit Care Clin. 2010;26:207-17.
3. Dreyfus S, Dreyfus H. A five stage model of the mental activities involved in directed skill acquisition. California University Berkeley Operations Research Center [monograph on the Internet]; 1980. www.dtic.mil/dtic/tr/fulltext/u2/a084551.pdf. Accessed April 6, 2015.
4. Dreyfus H, Dreyfus S. Mind over machine: the power of human intuitive expertise in the era of the computer. New York: Free Press; 1986.
5. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83:761-7.
6. Benner P. From novice to expert: excellence and power in clinical nursing practice, commemorative edition. Upper Saddle River, NJ: Prentice-Hall; 2001. pp. 13-36.
7. The University of Texas MD Anderson Cancer Center website. Postgraduate Physician Assistant Program in Oncology. www.mdanderson.org/education-and-research/education-and-training/schools-and-programs/clinical-education-for-non-physicians/physician-assistant-program-in-oncology/index.html. Accessed April 6, 2015.
8. The University of Texas MD Anderson Cancer Center website. Postgraduate Fellowship in Oncology Nursing. www.mdanderson.org/education-and-research/education-and-training/schools-and-programs/nursing-education/post-graduate-fellowship-in-oncology-nursing/index.html. Accessed April 6, 2015.
9. Ohio State University Comprehensive Cancer Center – The James website. Acute Care Oncology Fellowship Program. http://cancer.osu.edu/cancer-specialties/nursing/acute-care-oncology-fellowship-program. Accessed April 6, 2015.