High-performing organizations, Bigler says, had clearly defined and standardized APP roles. For instance, were they a practice extender, collaborative provider, or independent provider? They also had to develop governance structures and a centralized forum for practices and policies.
"We had to develop governance structures, because you don't want some of your most valuable people wondering where they fit in," she says.
At Carle, as with other systems, APPs are used not just in primary care, but all over: in surgery, rounding, screenings, consults, acute care, ED, convenient care, and case management, for example.
"There's a lot they can do, and we needed to push those roles to a coordinated team delivery model," she says.
To implement best practices they learned, Snyder says they were helped by a "strong dyad medical director VP structure" with physician leadership fully integrated into operations.
"In other words, we have docs leading other docs," he says. "When you have that dynamic you can be effective."
Holes in evidence-based medicine
Leonard, Carle's president and CEO, is comfortable with the change because to him it doesn't mean that physicians don't have input into management of their APPs, it just means they do it as a group, and not individually. And management of the group as a whole doesn't mean necessarily always following treatment protocols and evidence-based medicine guidelines that may not fit a particular patient's diagnosis.