Advanced Practice Providers on Neurology Teams

The American Academy of Neurology (AAN) issued an updated position statement, Neurology Advanced Practice Providers in 2020,¹ noting there has been an increasing number of nurse practitioners (NPs) and physician assistants (PAs) joining neurology care teams. The statement aims to clarify advanced practice providers (APPs) roles in neurology in order to better improve access, increase efficiency, and enhance quality of neurologic care. The AAN also notes that if these goals are achieved, it may reduce the need for emergency care for neurologic conditions. The position statement will be especially valuable for areas of neurology that have not typically had APPs regularly involved.

Physician Led & Collaborative Teams: The Example of Comprehensive Multiple Sclerosis Centers

Much can also be learned from subspecialties that have long included APPs in care teams, such as multiple sclerosis (MS) and epilepsy. The Consortium of MS Centers (CMSC), for example, has been a proponent of comprehensive and collaborative teams for many years, using a model that places the patient at the center (Figure).²

In this model, as in the revised AAN position statement, neurologists are essential to the diagnostic evaluation and development of care plans. The AAN guideline also endorses the need for physician-led multidisciplinary teams, noting that this concept is also advocated for by the Institute of Medicine (IOM), the American College of Physicians (ACP), and the American Medical Association (AMA).¹ The CMSC model centers the patient within a team that surrounds and supports them, within a construct that each member of the team has a specific and equally important role to play in patient care.^2-5 Comprehensive epilepsy care centers have a similar model for individuals with drug-resistant epilepsy who need a level of care that may not be achievable by a general community-based neurologist.⁶

In practice on MS care teams, after neurologists have made the diagnosis and created a treatment plan, it is often the APP who coordinates and leads the work of the team. For example, if a person with MS is having cognitive issues, which are quite common with MS, the APP can conduct screening examinations to determine if a neuropsychology consult is required. APPs can also ensure that psychiatric care is provided if anxiety, depression, or other mental health concerns arise.

In this construct, it is also strongly encouraged that patients have a primary care clinician because individuals with chronic neurologic diseases may make the mistake of considering their follow-up neurologic care as all they need. APPs can educate patients on the need to have a primary care clinician for preventive care (eg, cancer and heart disease screening) and acute care (eg, colds or allergies). APPs can address these needs, which can improve access to neurologists for initial consultations and the management of more complex cases. At the same time, care of specific patients is often discussed in team meetings, which are usually led by the neurologist with a focus on the individual’s progression within the course of MS and whether treatment changes are being considered.

APPs, especially NPs, have traditionally had a focus on patient education as well. In that context, once the neurologist or entire team develops treatment options for an individual, it often falls to the APP to provide education about the risks and benefits of those options. Although they are not APPs, specialty pharmacists are also starting to play a greater role in patient education about treatment risks, especially within Food and Drug Administration (FDA)-mandated programs for risk evaluation and management strategy (REMs) programs. APPs and specialty pharmacists may also play a role in handling prior authorizations and other issues related to reimbursement for neurologic drugs that are among the most expensive.

Advanced Practice Providers

Advanced Practice Nurse Education and Training

Advanced practice registered nurses (APRN) complete a Master of Science (MSN) or Doctor of Nursing Practice (DNP) degree. Programs that grant such degrees, whether courses are online or in-person, are accredited by the American Association of Nurse Practitioners. All programs must require that applicants have obtained a Registered Nurse (RN) certification and have an active license to practice, which requires obtaining an associate degree or, more typically, a Bachelor of Science in Nursing (BSN) and passing the National Council Licensure Examination (NCLEX).⁷ Most programs require the BSN as well as 1 or more years of clinical practice as an RN.

Accredited programs must offer didactic and clinical rotations with demonstration and documentation of clinical competency that builds on basic nursing skills. To encourage a more diverse nursing workforce and increase attainment of higher nursing degrees by people from traditionally underrepresented groups, accelerated “bridge programs” have been developed and may shorten the total time to earn an advanced degree. Other programs may be extended to make it easier to earn advanced degrees while still working clinically.⁷ In addition nursing education, including advanced practice education, is in the midst of a 3-year transition to competency-based education, similar to that of medical education.⁸

Within advanced practice nursing degree programs, it is possible to become a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse midwife (CNM), or NP. Advance practice nurses may also further specialize in pediatrics, gerontology, family practice, obstetrics, and psychiatry/mental health care.⁷ Although NP scope of practice varies at the state level, all have licensing requirements that require the national examination and recertification at the advanced practice level.^7-9

Physician Assistant Education and Training

The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) is the accrediting agency that defines the standards for physician assistant education, setting standards for the curriculum and the required 5,000 hours of clinical rotations.¹⁰ Admission requirements vary by program, but typically include basic sciences of anatomy, physiology, chemistry, biology, and microbiology. Although many programs also require prior experience with some hands-on patient care, this requirement varies widely, ranging from being an emergency medical technician (EMT) or medical corpsman to surgical technician, or certified nursing assistant. According to the American Academy of Physician Associates (AAPA), most applicants have a bachelor’s degree and 3 or more years of experience in a health care-related position.¹¹

PA training results in a master’s degree. Certification requires passing a national standardized examination, the Physician Assistant National Certifying Exam (PANCE) administered by the National Commission on Certification of Physician Assistants (NCCPA). Licensure is at the state level and requires continuing education and recertification every 10 years.^9-11

Subspecialty Education and Clinical Experience

APPs do not necessarily train specifically for subspecialties of medicine (eg, neurology or cardiology), although after their formal training they may complete subspecialty certifications. During training for the NP or PA degree, neurology training may be limited to 6 to 8 weeks, just as it is for many medical students. This is true whether the APP program is at the level of a master’s or doctoral degree. Unless the student has a specific interest and can arrange training in a particular specialty, they may not have significant clinical experience specific to neurology. This can make onboarding onerous for the physicians and other members of the existing team, especially considering that time spent onboarding may not be considered for relative value units (RVUs) or protected time for the physician.

Onboarding challenges also lead to difficulty retaining APPs in specialty settings such as neurology, which create costs and inefficiencies.¹² Structured orientation programs with proctoring and mentorship have been shown to improve retention rates, reinforcing the importance of specialty-specific clinical training programs.^12-14

Duke University (Chapel Hill, NC), Memorial Sloan Kettering (New York, NY), and the Geisinger Health System (Danville, PA) offer a 1-year training programs in advanced clinical neurology for APPs. No other formal education yet exists for APPs in neurology. The AAN position paper on the use of APPs in neurologic practice notes the resources available and needed for continued integration of APPs (Box 1).¹

Although additional qualifications in some specialties are available for both NPs and PAs, this does not include neurology, and there are no specific neurology or neuroscience board examinations for NPs or PAs.^10,15 The National Headache Foundation offers a certificate of added qualification in headache medicine for all members, including NPs and PAs as well as physicians.¹⁶ A subspecialty credential in neuroscience or stroke nursing (Certified Neuroscience RN [CNRN] or Stroke Certified RN [SCRN], respectively) from the American Board of Neuroscience Nursing (ABNN) does not require an advanced practice nursing degree or certification. Rather, this credential is available to anyone licensed as an RN who has completed 2,080 hours of direct or indirect neuroscience nursing care in a 3-year period and passes the CNRN or SCRN standardized examination. The ABNN also offers a certificate in seizure and epilepsy health care that requires completing training modules and passing a standardized test. The epilepsy and seizure health care certification is also available to anyone who holds an RN license and is not limited to APRNs.¹⁷

The Question of Independent Practice

In 49 of 50 states, PAs are required to work under the supervision of or in collaboration with a physician.¹⁸ NPs can practice without physician oversight in 23 of 50 states and Washington, DC; in 11 states, NPs are required to have physician supervision for diagnosis and treatment as well as prescribing.¹⁹

Once an APP has developed experience within a specialty, it is very unusual for them to change specialties, particularly if they wish to develop an independent practice where that is allowed. Typically, only highly experienced APPs with many years of experience venture out into independent practice and rely upon established patient-clinician relationships to make an independent practice viable.

In the experience of the author, where independent APP practice is allowed, the relationships of the APP with other care providers is essential, particularly in neurology. APPs need working and collaborative relationships with neurologists, imaging centers, neuropsychologists, psychiatrists, rehabilitation specialists, and more. Fitting into systems of care with a strong referral network and relationships with individuals who have hospital admitting privileges if the APP does not are also critical. Even if the APP is in a separate or satellite office, they will not be able to meet all the care needs of people with neurologic conditions, which with rare exceptions are lifelong chronic diseases. Patients’ needs include nutrition, exercise, physical therapy, disease-modifying treatment, and social opportunities that require a team of care providers as in the CMSC model (Figure). To be successful, this must be seen and implemented as adding resources for patients rather than reallocating employment opportunities among clinicians.

For both practices and patients who work with APPs, it is important to assess the practitioner’s level of experience by asking questions about their training, their clinical experience, and the symptoms or disease states that they are likely to treat. As with any clinician a person chooses to work with, willingness to answer these types of questions and make this information publicly available can serve as litmus test for open and transparent communication and shared decision making.

Comprehensive Care Centers Without Walls

Independent practice can occur within a collaborative and comprehensive model, which does not necessarily require being in the same physical space. This is the concept of a comprehensive care center without walls. Returning to the example of MS and recognizing that only 33% of people with MS receive care at comprehensive MS centers, collaboration across geographic bounds is necessary to achieve best-practice multidisciplinary care.^20,21 This is especially true for patients who live in areas where there is a paucity of neurologists. Comprehensive care independent of geographic location may also help address disparities in care. For example, it has been shown that people with epilepsy with Medicare-Medicaid who live more than 30 miles from comprehensive epilepsy centers do not receive care in this setting, whereas access to these centers for people with private insurance is not limited by distance.²² Teleneurology, which has been a great success and silver lining of the COVID-19 pandemic, can further enable comprehensive centers without walls.

What to Ask When APPs Join Neurology Teams

What Should the Neurologist Ask?

For the neurology practice or team, the most beneficial starting point may be asking themselves what the role of an APP is or would be within their team. Clearly defined responsibilities are essential to all team-based care. Knowing what responsibilities an APP will have can guide questions about specific clinical experience and knowledge of candidates for the position. Being clear about the expected responsibilities and role of an APP will help you find the best candidate as well as recruit and retain APPs.

There are also general questions that should be asked of any candidate (Box 2). Asking and verifying where someone received their APP education and making sure it was an accredited program is essential. Candidates should be prepared to verify their certification, recertification, and licensure status. In a state with independent practice laws, reasonable restrictive covenants (ie, noncompete clauses) could be considered just as they would with a physician joining a practice.

Because communication and shared decision making are essential to team-based patient-centered care, it is helpful to assess these as much as possible. Letters of recommendation and references from previous practices where they have worked can be useful in this regard. Priority areas for patient-centered care for chronic conditions include healthcare knowledge, cultural competency (accessibility/inclusion), a commitment to ongoing communication, and wellness (ie, diet, exercise, and spiritual/social wellbeing).²³ NPs may be especially well suited to patient communication, education, and wellness as these are emphasized in their training.⁸ Salary negotiations can include dedicated money set aside for specialty-specific conferences, continuing education, and certification courses.

What Should the APP Ask?

For APPs considering a practice, in the author’s experience, it is important to get a good general feel for how the practice works. For example, if there are 4 neurologists in the practice, do they function independently or work as a team, covering each other for calls and discussing patient care together? Are there people in the practice who subspecialize, for example in headache or movement disorders? Understanding the APP’s role based on how the practice is structured is also crucial. Would an APP work with all the practice members or only some? Does the practice want an APP who sees a broad range of neurologic conditions or are they seeking someone for a specific role, such as an epilepsy care coordinator?

APPs should also ask questions that reassure them they will not simply be relegated to care for those patients whom the neurologists prefer not to see for various reasons. Instead, the APP should be able to develop long-term relationships with patients who have conditions requiring ongoing care that do not always require the expertise of a neurologist. A practice should be able to give examples of when and why an APP would take on a particular patient (eg, as the disease progresses, there may be a need for a larger and more varied care team that requires coordination, or, in contrast, a patient who is stable on their medications and needs only routine follow-up care). Similarly, it would be helpful to discuss when an APP might choose to involve the neurologist and perhaps other members of the team (eg, new or significantly worsened symptoms, a reaction to medication, or a desire to change the treatment plan).

Other questions are more specific to each APP as an individual. Does the practice fit with your vision of how best to provide neurologic care? Are you more comfortable implementing a plan that the physicians create, or do you want to be involved in creating care plans with the physicians? Alternatively, some APPs may want the autonomy of being the person who creates the plan for specific aspects of care or specific patient groups. Identify how much autonomy you want and how much a practice is willing to negotiate.

Conclusions

APPs are and should be integral members of physician-led or team-based comprehensive care teams in neurology and other specialties or subspecialties. Specialty-specific training, continuing education in neurology, and additional certifications can benefit APPs and the entire practice and should be considered part of recruitment, onboarding, and retention best practice. On functional teams, the APP often serves as a care coordinator who may delegate to other members of the team as each team members specific skills are needed. APPs may have more time with individual patients and different communication styles that allow them to see the need for readjustment of the care plan, from life changes (eg, death of a spouse, divorce, or a sick child) to medical changes (eg, symptom worsening, new symptoms, or a new comorbid condition). Among the most important aspects of APPs and physician collaboration is defining roles and responsibilities within the collaborative framework with the patient at the center of it all.