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Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.</metaDescription> <articlePDF/> <teaserImage>299995</teaserImage> <teaser>Advanced practice providers are a cornerstone of strategies to bolster the shortage of rheumatologist across the United States, and here are many of the considerations that rheumatologists need to keep in mind when hiring, training, and retaining them.</teaser> <title>Best Practices for Hiring, Training, Retaining Rheumatology Advanced Practice Providers</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>rn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">26</term> <term>21</term> </publications> <sections> <term canonical="true">27980</term> <term>39313</term> </sections> <topics> <term canonical="true">38029</term> <term>290</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240125cc.jpg</altRep> <description role="drol:caption">Stacy Yonker</description> <description role="drol:credit"/> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240125cd.jpg</altRep> <description role="drol:caption">Christine A. Stamatos</description> <description role="drol:credit"/> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240125cb.jpg</altRep> <description role="drol:caption">Julia M. Swafford</description> <description role="drol:credit"/> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240125ca.jpg</altRep> <description role="drol:caption">Dr. Mark Box</description> <description role="drol:credit"/> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240125c9.jpg</altRep> <description role="drol:caption">Katie Taylor</description> <description role="drol:credit"/> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Best Practices for Hiring, Training, Retaining Rheumatology Advanced Practice Providers</title> <deck/> </itemMeta> <itemContent> <p>Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices. </p> <p>Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said. <br/><br/>[[{"fid":"299995","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Stacy Yonker, chief executive officer of Sarasota Arthritis Center, Sarasota, Florida","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Stacy Yonker"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]]Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists. <br/><br/>Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires. <br/><br/>[[{"fid":"299996","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Christine A. Stamatos, director of the Fibromyalgia Wellness Center within the Division of Rheumatology at Northwell Health in Huntington, New York.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Christine A. Stamatos"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]]“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.<br/><br/>“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will. <br/><br/></p> <h2>Why the Profession Needs APPs</h2> <p>Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have <span class="Hyperlink"><a href="https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr.23518">projected troubling shortfalls</a></span> in rheumatologists over the next decade in all regions of the United States. </p> <p>Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.<br/><br/>Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective. <br/><br/>[[{"fid":"299994","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Julia M. Swafford, a rheumatology physician assistant in Battle Creek, Michigan","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Julia M. Swafford"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.<br/><br/></p> <h2>Hiring Someone With Experience</h2> <p>Recruiting and retaining APPs is not without its challenges.</p> <p>[[{"fid":"299993","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Mark Box, medical director of Carondelet Rheumatology in Kansas City, Missouri","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Dr. Mark Box"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said. <br/><br/>The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.<br/><br/>[[{"fid":"299992","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Katie Taylor, practice manager of Carondelet Rheumatology in Kansas City, Missouri","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Katie Taylor"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.<br/><br/>When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.<br/><br/>Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice. <br/><br/>He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”<br/><br/>The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said. <br/><br/>Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.<br/><br/>New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps. <br/><br/>Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised. <br/><br/></p> <h2>Shadowing the Physician</h2> <p>Partnerships with physicians is a critical component to this onboarding process. </p> <p>A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added. <br/><br/>The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”<br/><br/>At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.<br/><br/>“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said. <br/><br/>Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases. <br/><br/>At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.<br/><br/>At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added. <br/><br/>The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients. <br/><br/>It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient. <br/><br/></p> <h2>Education Resources for Practices</h2> <p>In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency. </p> <p>Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added. <br/><br/>In a <span class="Hyperlink"><a href="https://www.jrheum.org/content/49/6/555">recent editorial</a></span>, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an <span class="Hyperlink"><a href="https://careerconnection.rheumatology.org/career-advice/youre-a-new-nppa-in-rheumatology-practice-what-now/4899/">online curriculum</a></span> developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.<br/><br/>“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.<br/><br/>Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”<br/><br/>In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an <span class="Hyperlink"><a href="https://www.bonehealthandosteoporosis.org/patients/communication-with-your-doctor/fracture-liaison-service-fls/fls-certificate-of-completion/">osteoporosis fracture liaison certification</a></span> which we put APPs through as well,” she added.<br/><br/>Rheumatology practices should also look into an important clinical training <span class="Hyperlink"><a href="https://www.rheumresearch.org/file/FY24-Mentored-NPPA-Award-for-Workforce-Expansion.pdf">grant program</a></span> from the Rheumatology Research Foundation, Dr. Stamatos advised.<br/><br/>To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1. <br/><br/>For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.<br/><br/>APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.<br/><br/>“That’s a huge thing that’s probably missing,” Ms. Swafford said.<br/><br/></p> <h2>Buy-in From the Doctor</h2> <p>No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.” </p> <p>Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.” <br/><br/>In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.” <br/><br/>Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer. <br/><br/>“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”<br/><br/></p> <h2>When APPs Make a Difference</h2> <p>Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said. </p> <p>Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.<br/><br/>Sometimes, an APP will go beyond their scope of work to make a difference and better support patients. <br/><br/>Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.<br/><br/>She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists. <br/><br/>The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added. <br/><br/>APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.” <br/><br/>None of the sources reported any disclosures or conflicts of interest.<span class="end"/></p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
