Zachary Hartsell, PA-C, MHA, associate professor and director of Physician Assistant Services at Wake Forest School of Medicine, describes the current make-up of advanced practice providers (APP) in cardiovascular medicine and the role of APPs in cardiovascular population health management. He also explains outcomes data associated with APP care and optimal models of APP deployment in the care of patients with cardiovascular disease.
View Doctor Profile ZACHARY HARTSELL: I'm Zac Hartsell. I'm Director of PA Services at Wake Forest Baptist. We also have a Director of Nurse Practitioners, which I'll talk a little bit about our structure going forward. But Megan and the group today asked me to speak about today's advanced practice provider/ So just a quick poll in the room. How many advanced practice providers, CRNAs, PAs, nurse practitioners, CRNAs, certified nurse midwives, in the room? Handful? Couple? OK. How many physicians in the room? A couple, a handful. Nurses? OK What about, say, techs that work in the angiography suite? Any techs? No? OK. So today, we're going to be talking really about the advanced practice provider. I have no disclosures. And the objective's really going to talk about how the makeup of advanced practice providers workforce in the cardiovascular specialties. I'll also talk a little bit about advanced practice providers in the primary care workforce and how that supports cardiovascular subspecialties. We're going to talk about the role of APPs in cardiovascular population health management. That's a big buzzword right now. So we'll talk a bit about that. And then also talk about some optimal models for APP deployment and, hopefully, hear a little bit from you guys about what models you have seen and what models may be working where you're working. So a little bit about us. I'm sure you've heard a little bit about Wake Forest already. But we're obviously at three-hospital system in Western North Carolina. We've got about 1,004 acute care, rehabilitation, long-term, and psychiatric care beds. Our main hospital is Baptist, obviously. We have 885 acute care beds. We are a Level I trauma center. US News ranks us as high performing in cardiology and heart surgery. One thing that a lot of people don't know is we actually have three ranked educational programs. So both our [INAUDIBLE] school is ranked. Our CRNA school, as I recall, is ranked number one in CRNA schools. And the PA program, we're ranked number nine in the country. So a lot of well structured and well designed education programs at Wake Forest Baptist. We're really a leader in biomedical and health science research in Western North Carolina, especially in the region. And we have this new focus on diabetes/obesity/metabolism and the associated cardiovascular disorders. And so I know that talking with, say, our endocrinology colleagues, their focus has really been on how do they prevent diabetes from getting into the cardiovascular risk factor, or at least, from progressing that way. And so it's not just cardiology or vascular surgery or CT surgery that's having these discussions. It's really the whole organization. And we've been a Magnet Accredited facility since 1999. And I think-- is it this week, Fran, that we're getting the announcement of the-- or we're going to Magnet and getting the award? Yes, this week. Yes, this week. So we've gotten recertified as a Magnet center. And I think that a lot of Nursing is there now, having the big presentation. So we're really excited about that. So what about our advanced practice providers? We've actually been using advanced practice providers, advanced practice nurses, and PAs since the 1980s. For the PA profession, we're one of the originators of the PA profession in the country. We are the number four started program in the country. We've also been using nurse practitioners and CRNAs for that long, as well. And again, how we define, Wake Forest Baptist Medical Center defines, advanced practice providers are certified nurse midwives, CRNAs, clinical nurse specialists, nurse practitioners, and physician assistants. There's lots of different terms that we use for these. Sometimes, we call them at mid levels, which is a term that we've moved away from as an organization, because that then implies that there's a high level and low level. Ideally, we'd like to use the person's title, so a nurse practitioner or a PA. But knowing that sometimes, when you're talking about workforce, you're talking about collections of people. And so we've used the term advanced practice provider. We have about 350 certified nurse midwives, nurse practitioners, and PAs. And we've got about 150 CRNAs at Wake Forest Baptist. So it's something that we have a good workforce, especially in North Carolina, as a size. We're a little smaller than Carolinas Medical Center, who's got a few more than us. But I think, in terms of other medical centers in the state, we're actually one of the-- have a pretty large workforce. We've also recently developed a formalized leadership structure. So we have a director of nurse practitioners, who is Elisa Starbuck, who is also our chief nursing officer for Baptist. We have a director of PAs, who is myself. And we recently started an advanced practice council. So we have leaders from within different service lines and different areas within our medical center that come together. We meet usually once a month, sometimes a little more often. And we discuss issues that are to all advanced practice providers throughout the organization. We're focusing a lot on structure, a lot on things like workforce development, how to optimize our workforces, how to look at things like productivity, benefits, those kind of things. So it's a group that we're getting together to discuss the issues that really are of importance to advanced practice providers. And that's something that we've recently started and has been, I think, a real great success. So I know we have some advanced practice providers in the room. But I know that there's some that are not. So just who are we talking about? So today's talk, really, given the space, is going to be either nurse practitioners or PAs. We're mainly going to be working on the cardiovascular side of it. Certainly, CRNAs and certified nurse midwives can have roles in helping with cardiovascular health. But a predominant are going to be either nurse practitioners or PAs. So just a little comparison of nurse practitioners and PAs. So nurse practitioners are moving to a doctorate-level program. Still, a majority are master's-level trained. But I know the profession is moving to a doctorate. They really have a blended education model, so thinking about both nursing and medicine, and really using that holistic approach. And it's a joint regulation by the state-- in North Carolina, it's jointly regulated by the state nursing board and the medical board. In some states, that's a different makeup. And that determination is state by state. In North Carolina, there is prescribing authority. And that certification depends on the type of nurse practitioner training you go and get. So depending on what you have and where you're working is going to determine what kind of certification. For PAs, we're a master's-level profession. We are really focused on the medical education model. The PA profession, in its roots, really started as using the model they used to train physicians in World War II. During World War II and the Korean War, they had a rapid access training for physicians, to be able to get them into roles in MASH units, and those kind of things. And the curriculum for PA education was based on that rapid training that they used, and so it really is focused on a medical model and aligned with the medical school curriculum. We also have prescribing authority in North Carolina. And we have a single-source, 10-year certification. It's recently moved to a 10-year certification. It was seven years before that. And again, what's interesting is when you-- and Lisa Starbuck and I talk about this all the time-- North Carolina is one of the interesting states. There's wide variety among states about how NPs and PAs are utilized. Some states have regulations and laws that are a little more nurse practitioner friendly. Some have a little more PA friendly. In North Carolina, if you look at the two regulations, now, like with anything, they've restructured it, and it's in different orders. But if you actually take the legislation and you put it over each other, it's almost word for word identical. Again, it's reordered a little bit differently. Some states, there's, I know, a bill pending about more independent practice for nurse practitioners. I've heard mixed things about where that is, in terms of going to be able to pass or not. But currently, right now in North Carolina, really the use of NPs and PAs are almost equivalent in any of the practice settings. From a Medicare standpoint and from billing standpoint, most all insurers view NPs and PAs as identical. And so usually, if there's a insurer or a private insurance company that's going to take NPs and PAs, they'll take them both or they'll not take them at all. Occasionally, they'll take one, versus the other, but typically they fall hand in hand. And certainly, from Medicare, the 85% reimbursement rule applies to both nurse practitioners and PAs. So how many are there in North Carolina? So there's nine accredited PA programs. And actually, two just got accredited this week, so that's going to bring the total of PA programs up to 11. And there's eight accredited nurse practitioner programs. There's almost equal amounts of NPs and PAs across the state. And I can say that, workforce-wise, I actually looked up the numbers, both on the nurse practitioner side and the PA side. It's really murky as to figuring out who is exactly working in cardiovascular services, mainly because they ideally usually will list it as primary care, medical subspecialty, surgical subspecialty. And so, depending on your definition of cardiovascular care and cardiovascular health, it seems to me that they're somewhere between 7% and 9% of the workforce for both NPs and PAs working directly in cardiovascular, and probably another 20% to 25% that are working in some kind of cardiovascular supportive role, either in a primary care setting or in something like endocrinology, that would be directly support it. As a health care industry, we've tried, obviously, the Affordable Care Act. We're moving ourselves to more of a value-based care model, so moving away from that fee for service, that is, a fee for transaction. You see a patient. You get a fee. Moving to the more value-based care model, which is we're looking at outcomes. We're looking at how your patients are performing, and then you get paid as such. So looking at patient, consumer, centered strategies. So things like telehealth, things like extended office hours, are all geared towards making it easier for the patient to get in and get some care. And I think that those things are going to continue to really move forward, especially as we start to move to pooled models of care. So a pooled model of care is a capitated model, which is you would get a lump sum of money to care for a population. And you don't get any more money. So if the patients do really, really well, you get those savings back to you as a practice. If your patients get really sick, then you're going to have some of your salary. Or your income to your practice is going to be on the line. So I know, Wake Forest Baptist, we've entered into a clinically-integrated network to share the risk of some of these population pools, so that we can help try to save on these cost savings to other practices in the area, and to our patients, ultimately. So what are some of the strategies? Well, hospital partnerships. So we've been partnering with lots of different hospitals to do that. Physician and provider partnerships. So thinking about how Wake Forest Baptist or how different groups of providers get together and manage patient populations. And then, thinking about innovative care models. So we are currently, right now, our PA program is entering into a study with Appalachian Regional. And we're looking at telehealth in rural communities. So thinking about how we can provide access to care to people who live in really remote areas, who may have not really great internet access. And so how do we use, say, for example, cell phone technology to develop some kind of relationship with these patients who maybe don't have any kind of internet service where they live? Maybe they do have cell phone service, but it may be a long trip for them to get in to see the provider. How do we manage their chronic condition in those kind of situations? This is going to be key going forward. And this is going to be what, I think, is going to help move the dial, in terms of our efficiency, financial efficiency, compared to other models-- is that if we can get out there and care for these people in rural communities, especially, or under-served communities, and bring the care to them, and help lower the cost of care by preventing complications or the end outcomes of diseases. That, to me, is where the health care system can make a huge difference. And that's everyone in this room, right? The nurse practitioners, PAs, nurses, our primary care providers. Moving into these innovative models are really going to be where the secret sauce is. In terms of the reform financial and payment models, we're seeing this already. So some of this is through the shared savings. So again, we have good patient outcomes. So we either get more-- we save money to our practice, or we get bonuses for having good outcomes. And we can also send some of those cost savings on to our patients. So the cost of care is rising so much. There's a lot more out-of-pocket expenses. And so as practices save money, we can potentially push on some of those cost savings to our patients, as well, and hopefully lower the overall cost of care. So what's our ultimate goal? Well, it's going to be the triple aim, right? So it's efficient cost or low cost, high quality, and great access. And I think that NPs and PAs especially are the cornerstone to help make this happen. So it doesn't mean that you don't need physicians in this model. You absolutely need physicians in this model. And we need lots of physicians in this model. But what we need to do is we need to build those models efficiently, so that the physicians and the specialists in those areas are having the largest impact on the community. But I definitely think that NPs and PAs can help in all of these areas. And we'll walk through some of our examples of how I think they can. So when we talk about population health and what our goal is, we really talk about it from a 15,000-foot view of, what are we trying for? Well, we're looking at clinical integration. How do we integrate our practices and all work together, communicate better? How do we do care coordination? So how do we move the patient from out of the hospital into the home environment? How do we transition them from, if they're in the home environment and they get sick, how do we make that as efficient transition into the hospital? So again, NPs and PAs can have significant roles in those. We have our transitional care unit. Our transitional care team, for example, looks at people who are our high utilizers of care, and building programs where we are proactive in their management. So contacting them regularly. And when we know they may need time for hospitalization, how can we help bring the services to them in their home, as opposed to having to bring them in? So data analytics, we've got a very-- our school of public health is really focused on data analytics and looking at how can we use data to help us identify the patients who are the high utilizers, or maybe populations that need excess care? There's a great article called, "Hot Spotting." Anybody read that article? It was about a couple years ago. They talked about how you can use data to help identify which patients may need care in the future. So this is like futuristic technology to-- was it Minority Report, when they were anticipating a crime before it was actually going to happen? This is the kind of thing, is you can, through data, actually sometimes identify when diseases or processes are going to happen before it even happens. So the example they used in "Hot Spotting" was, I think it was in Chicago, there was an apartment building. And the one ER in Chicago kept having a lot of ankle and lower extremity injuries. And so what they ended up finding is, through data analytics, it all came from one apartment building. And when they actually went out to that apartment building, they found that the stairs were in horrible repair. And people were falling and breaking ankles, and all that kind of stuff. And so what did they do? They fixed the stairs, and all of a sudden, all the lower extremity injuries stopped. And so this is the kind of thing, to say, yes, you can treat all the fractures that come in. Or you can go into the community and fix the underlying problem. And so using data is really powerful in those kind of capacity. Patient engagement, again, I think NPs and PAs, we're all trained in this model, in terms of really spending time with patients and looking at them holistically. And then aligning our revenue cycle. So moving away from this thinking of, we get paid per patient, to how do we provide good care for our patients? And the good outcomes are what leads to our practice making money and being profitable, not necessarily how many we see. And I think that this is an evolving place. We're not there yet. But I think that we're going to see more and more of these kind of models. So what does good population health care look like? And I wanted to bring this up, so that when we talk about our different models of NPs and PAs, how they're utilized, then we can look about how it meets each one of these different areas. So we have improved outcomes. We have lower cost, improved access, which is a huge thing. I know, at Wake Forest Baptist, that's one of the areas that we've really moved NPs and PAs into, is roles where we can help improve access to our patients. Better chronic care, better preventive care, and then high patient satisfaction. And so when I think about what places are doing this, I think about some of my colleagues at Cleveland. I have some colleagues at Cleveland Clinic that have actually looked at this and the roles of NPs and PAs in this. And so the way that Cleveland Clinic looks at their care and how they're delivering care is definitely along these lines. And they've used nurse practitioners and PAs to help fill those gaps. And so for example, at Cleveland Clinic, you show up in Cleveland today, you can get an appointment today. Well, how do they do that? So you can just show up in the Cleveland airport and call up and say, I want to see the cardiologist today. I want to see somebody in cardiology. And the way they do that is that they really maximize their use of their nurse practitioners and PAs. So either a service will use them so that you get in to see a nurse practitioner or PA that day, and the nurse practitioner or PA will triage you in a way to say, OK, let's get the test started. Let's get some orders started. Let's get the medications you need. And then we'll have you see the specialist next week, or in three days. Or they'll have the specialist see you up front. So you walk in. You see the world famous cardiologist. And then all of the patients that this person would normally be seeing in follow-up are seen by the NP or PA. And so they then really utilize the model of NPs and PAs and leverage that to help gain a better patient access. And so what happens with better patient access? Patients are happier. It's lower cost, because then you're not waiting for a delay. And we always hear the story where somebody couldn't get in on a Friday. We say, we'll get an appointment for you next week. And then what happens on Saturday? They show up in the emergency room, and they get admitted. And so we've lost that opportunity to help impact them. So I really think that looking at these kind of models are the things that we need to be doing. So how are NPs and PAs-- let's give some examples of how NPs and PAs are really utilizing this in those spaces. So how did PAs rate and NPs rate? So looking at outcomes, American Journal of Cardiology looked at outcomes provided by nurse practitioners and PAs, especially looking at diabetic outcomes. And they found that the outcomes between physicians, nurse practitioners, and PAs were essentially all equivalent, when using very standardized protocols in a practice that was designed for a protocol-driven system. And NPs and PAs had some autonomy, in terms of what they were able to do, but it followed into a very defined scope of care and defined scope of practice. Now, there's going to be patients that fall out of that. And that really is where physician colleagues and the ones that-- we have difficult patients, or we have complex patients or something that we need help with, can often be in those roles. But again, showing that when following the guidelines, nurse practitioners and PAs and physicians all work at about the same level, in terms of following clinical guidelines. Several different articles on lowering cost of care. Again, in terms of revenue generation, the American College of Cardiology says that PAs and NPs generate about three to four times their salary. But when you look at lowering cost, the addition of nurse practitioners on a academic teaching service significantly lower the cost of care for those patients. And then when you look at them in an inter-professional team, the combination of a physician plus an NP or PA, in providing care to the whole patient population within a practice, lower the cost of care. And so again, two models that shows that that addition of NPs and PAs lowered the overall cost of care. And then access. America Journal of Critical Care looked at improvement in access in outpatient clinics by utilizing nurse practitioners and PAs. Lots of data. Again, the article by Ohman-Strickland in, Annals of Family Medicine, really talks about diabetic management in family medicine practices and how the outcomes with patients with diabetes, when cared for by a nurse practitioner, were significantly improved, compared to the standard of care, or the usual care. One of the things that was interesting [INAUDIBLE] this article by Gambino, when you talk about patient satisfaction, the article shows that patients were actually happy. And there was a great article in Health Affairs, in 2013, which looked at patient satisfaction. So patients have a choice of, do you see a nurse practitioner or PA immediately? Or if you wait for the physician, and how does that affect your satisfaction? And again, as we would anticipate, patients just getting in and getting seen, having the problem taken care of, was a big satisfier. So moving this model from saying, you can only be seen by a physician in three or four weeks, to, say, can we be seen by a nurse practitioner or PA now? Get the tasks for the things that you need to be. And maybe you do need to see the physician, and we need to get into there. But can we start those tasks? Can we start to lower that cost of care and that time of care by getting you seen immediately? And then again, thinking about preventative care, PAs and NPs have been shown to provide really great preventative care, in terms of keeping on guidelines and recommending guidelines. Again, that was the article there about health affairs, about patient preference. One of the other interesting articles is looking at the role of PAs in proceduralist fields. So thinking about NPs and PAs working in interventional cardiology, and working in some of those spaces. So my experience is I worked at Lenox Hill Hospital, in New York, in interventional cardiology. I worked with big names in the profession, guys who have lots of stents named after them. And it was a great service. And we did a lot of the pre- and post-catheterization care. We ran a 24-hour service that cared for all the patients on the cath floor. And the reason the cardiologists were able to do the amount of caths they were able to do is because we were providing the care on the floor. There was a couple of groups in New York at the time that were actually starting to have their NPs and PAs doing diagnostic angiography. So typically, in a busy academic practice, a lot of the diagnostic angiographies are done by the cardiology fellows. And so cardiology fellows are, obviously, there for a certain period time, get trained, get supervised. And then they leave, and a new set needs to get trained. And so when I was in New York, there was a couple of practices that were using PAs in that role. So they were doing some of the diagnostic angiography. And there were some studies that came out of this that showed that the difference between a cardiology fellow and a PA, once trained, were insignificant. There was no difference in terms of the quality of the catheterization. And I know that, especially in New York, there are some practices that still use PAs in that role. The complicating factor for most NPs and PAs in this space is the Ionizing Radiation Acts in most states. So in most states, who can deliver ionizing radiation is heavily regulated. North Carolina is not one of those states. So anybody can actually show up. And the machines are heavily regulated, but who delivers them are not heavily regulated. So in North Carolina, PAs and NPs, if delegated or in their agreement with their supervising physician or collaborating physician, can actually deliver ionizing radiation. We're in the minority of states that allow that. Most states, you have to either be a physician or a radiation technologist to be able to do that. But North Carolina is a little different. So thinking about a different model of using NPs or PAs. So what are examples of some of the team-based care models? So what I've done is gone through and talked to some of my colleagues in cardiology and looked at our own practices at Wake Forest Baptist. I wanted to give you an overview of some of the ways that NPs and PAs have been successfully utilized in cardiovascular support, of cardiovascular care. So how do we look at these care models? Well, there's a lot of things that govern it. This is a whole talk in itself in terms of what you're able to do. And a lot of that is governed by state law. Again, in North Carolina, the state laws are actually fairly progressive in terms of what NPs and PAs are allowed to do. And it really focuses around that relationship with the supervising or collaborating physician. NPs and PAs use a little bit of different terminology for that. But that person really dictates and governs what you're able to do and not do. And so hospital bylaws also play a big part. And this is where, I don't know, in North Carolina, the Independent Practice Act, how that's going to affect with hospital bylaws. Most hospital bylaws are still built on the model that we have now. And so how that will change I'm not certain. But hospital bylaws have a significant role in looking at what an NP or PA is able to do. Practice type, setting, what the needs are of the service. This is usually the first call. When I get, as director of PAs, when a service calls me and says, we're looking at our model of PAs or NPs. What do you think? The first question I ask is, well, what do you guys need? What is it that, ultimately, your service is looking to do or perform by having a nurse practitioner or a PA? And then looking at the experience of the advanced practice provider and the experience of the physician. So there's just some physicians that have been trained with NPs and PAs and are very comfortable with those models. And there are some physicians that are not as comfortable with those models. And that's not a bad thing. It's just their comfort level with that. And so ideally, a good practice is going to be at the level of the NP or PA, at the comfort level of the physician, in terms of what they're looking to delegate. And it's going to fill the needs of the patient population and so that, if you think about the idea of practice. When we look at practice models at Wake Forest Baptist, we look at them in really three different areas. We have what we consider autonomous, which is the NP or PA is seeing patients on their own, has a supervising physician that is providing oversight and regulation and support as needed, but really are working as-- this is the family practice model, where you've got your panel of patients. I have my panel of patients. We'll certainly need to talk throughout the day, but our schedules are side by side, and we're both seeing as many patients as we can and getting through. We have the coverage model, which is as you think about your inpatient services. So somebody needs to be there 24/7. It can be a physician, but it doesn't have to be a physician level of care. It can certainly be an NP or PA level. And the skill sets that we have often sometimes are really great in those roles. And so thinking about inpatient services and such. And then there's the efficiency model. So this is what I look at as my role when I was working in the cath lab service, which is I was on the floor, and I was discharging and admitting those patients, so that the physician could stay in the cath lab and do more catheterizations. So I'm making the physician's process more efficient in that way. And again, looking at that, that's really a team-based metric. So when we look at our models, that's how we categorize them. And the ideal practice model is some combination of the three, right? In some practices, it may be very heavy autonomous, that I'm working, and then my physician colleagues or my supervising physician's working alongside of me, and we're doing our thing. But there may be other models where the work I'm doing is helping that physician be able to do some procedure or some skill based that really only the physician is trained to do. So what are some of the models? So thinking about cardiology inpatient service, I think that this is a really popular model, especially after the ACGME duty hour restriction took hold and got a lot more restrictive a few years ago. And certainly, I know a lot of inpatient services have expanded their use of NPs and PAs. Anybody familiar with this model? Anybody working in the hospital, who sees NPs and PAs caring for those patients? A couple. So this is mainly, again, in that coverage mode, when we think about it. So oftentimes, the cardiologist will be doing something else, either another procedure or maybe covering another clinic. And there needs to be somebody in the hospital, per regulation or per policy or just per patient need, to get that patient some care. The key on these is looking at innovative service design. So how do we make this efficient? And so is it, are we covering certain services? Wake Forest Baptist, for example, the NP and PA inpatient service covers very specific patients. And we've even used, for example, some of our advanced heart failure patients are cared for by NPs and PAs on a very specific service. So cardiology outpatient services. So this is really where PAs and NPs can help improve access. So thinking about new patients, so are they just getting people in or ordering the tests that need to be done, and then they schedule them with the cardiologist? Is it looking at people who maybe call up that day and say, I've been a long-standing patient here, and I need to be seen today. Can the NP or PA help with that? Or the post-hospital visit. So looking at we know that there's a heavy burden of care right after the post-hospital. So can NPs and PAs provide that care? Ideally, autonomous models are the best. Sometimes, efficiency models can work. The thing we found with clinic work is that if you develop a shared visit model, or you develop a model where every patient is seen by the PA and then by the physician, that tends to slow down clinic volume. And so you add the NP or PA to improve access and to improve care. And then you logistically slow it down by every patient has to be seen. And so your efficiency through the clinic really comes to a grinding halt. And so really thinking about how to be innovative with that. One of the things that there's been some good literature on is having PAs and NPs doing some of the screening procedures. So things like monitoring the stress testing, which oftentimes need to have a provider there to be able to interpret it or to be able to monitor. There's some good data that shows that the interpretation of these tests by either NPs or PAs or physicians, once trained, are equivalent. Thinking about doing ankle-brachial index readings and some of the other vascular readings, like aortic ultrasounds, could be both patient access help and to also be revenue generators for the clinics. And then also thinking about telehealth. One of our Wake Forest alum is working at REX Hospital. And she actually lives in Cleveland, but works at REX Hospital, in Raleigh. And she does all their telehealth visits. And so the patients get discharged from the hospital. And she is available to them. And they have software that they have lined up. And she provides a lot of the telehealth care. And it's helped reduce readmissions on to their advanced heart failure service. So a model that is very innovative, very different, but they're really leveraged the role of PA, in this case, somebody who's even out of state, in that role. So cardiothoracic surgery, again, a very popular specialty for NPs and PAs. The models are highly variable, but really focus on coverage and efficiency. That's been my main focus, or that's been my main experience with these, is that typically, it's either PAs and NPs are covering the floors so that physicians can be in the operating room or doing the procedures. Or they're providing coverage at night, in terms of somebody has to be here. It doesn't necessarily have to be the physician. It can be somebody else. First assist roles are very common. For PAs, this can be delegated. From nurse practitioners, it depends on the state. Some states can delegate it. Some states, you have to have an RN first assist license, to be able to work in the operating room. And again, some of that's dependent on state rules. Heart failure service, again, this is something that we've seen a lot of. When I worked at Mayo Clinic, they really had a very large and robust heart failure service that used NPs and PAs. And they really used them in that bridge role. So they would see them in the hospital and then see them as the first outpatient when they left, so that you had the same person seeing them. They also used the PAs as the longitudinal care. So what they would do is all the advanced heart failure patients would be seen by the physician at least twice a year. But all the other visits were seen by NPs and PAs. And so you would have very scheduled routine visits with the physician. But if you needed some care beyond that, then the NPs and PAs would fill those roles. And so it really became a team-based care model. And again, the role on transplant teams is evolving. But that's certainly something that you're seeing more of as heart transplant programs are launching. Family medicine clinic, again, this is in honor of PAs. So this is PA Week. In honor of PA Week, this is actually Gene Stead, who is the physician founder of the profession. But the traditional role for most NPs and PAs has been in family medicine. It's what most clinics were started as, as those roles. And again, it's thinking about roles in patient-centered medical home. And ideally, for cardiovascular standpoint, at least, you're looking at the identification and prevention of disease. You also can think about some of your screening procedures, as well. Procedural service. Again, we talked a little bit about some of the data on this. There are some services that are run by PA-- or that have PAs on them that do the diagnostic angiograms. Some services have PAs working on the EP service, both in the clinic, but then also in the lab, working as an EP tech role, doing some of the technologist roles in there. And that's a nice role, because you can have them as a prescriber and seeing patients in followup, but then also helping in the lab, as well. And again, usually a coverage or efficiency model, but the roles can be variable, depending on the service. What about us? What does Wake Forest Baptist do, because that's sometimes what people want to hear. It's like, well, it's great you showed me all these models. But what are you guys doing at Wake Forest Baptist? Well, we actually have a little bit of everything. So we have PAs and NPs working on the inpatient cardiology services, the outpatient cardiology services. We have our NPs and PAs working on our advanced heart failure service and our cardiac transplant. So I was just speaking with the practice manager of the heart failure service, to talk about the roles there. But we have two NPs, one on the outpatient side, one of the inpatient side. We have NPs and PAs on our CT surgery team, both the pediatric and the adult. Our CT surgery team has floor coverage and taking care of the patients as there's care throughout the hospital. And then we have PAs and NPs who work in the operating room, as well, and helping with the CT surgery team, in terms of harvesting veins and such. We have PAs on the EP service. And we have PAs and NPs on the vascular service, mainly providing floor coverage for the vascular surgeons. So we use NPs and PAs in all the different services at Wake Forest Baptist. And our challenge has really been, how do we start to innovate some of these models to move forward. And that's the space we're in right now. So how are we doing that? We're looking at trying to optimize the workforce to work at the top of their license. We developed these three models of care, like we talked about. And then we're now in the process of developing productivity and quality metrics for advanced practice providers. My colleague Lisa Starbuck and I are looking at how do we find the right combination of productivity measures? So things like RVUs and the traditional productivity measures, and how do we match those with quality measures so our patients are getting good outcomes. Or is there satisfaction? And then, what we've found is the key is to align those with physician metrics. So you can't be looking at it-- for a team, you need to be looking at the same metrics. And so it's just how do we align those, and how do we distribute effort, and those kind of things. And that's the our challenge right now, and that's what we're looking at, with some good success. We've had some good models when we've rolled this out. So any other models that you guys are familiar with? Anything that I missed in terms of a model that people have seen? I think I got them covered. So what are our take-home points? The NP and PA professions in North Carolina continue to expand and adapt. I think, as we see things like telehealth and population health, NPs and PAs are really going to move into those roles. Population health management will change the way we not only view chronic care, but probably how we view acute care, as well. And so thinking about some of our innovative models of in-hospital care. And then finally, NPs and PAs make valuable contributions of care of the cardiovascular patient.