The effective use of advanced practice clinicians (APCs) to provide primary care in a clinically integrated network (CIN) is exemplified by North Mississippi Health Services (NMHS) system, a health system based in Tupelo, Miss., that serves 24 mostly rural counties in the northeast corner of Mississippi and a few neighboring counties in Alabama. NMHS’s experience may anticipate the future for CINs nationwide. Ranking last among states in primary care physicians per capita, Mississippi has much of its primary care delivered by APCs, many of whom are in practices numbering one to three providers. In other words, the primary care provider mix in Mississippi today is likely a preview of tomorrow’s mix for the rest of the United States.
During its CIN planning stage, NMHS quickly realized it was not well aligned with APCs in the region because, like most health systems, it had been focusing its outreach efforts on primary care physicians in the market. It’s rationale for doing so was based largely on two premises. First, APCs in Mississippi are required to have a supervising physician, so to some degree, these supervising physicians would logically be the optimal point of engagement for a health system.
But the primary factor that had prevented NMHS from reaching out to APCs was its largely unspoken assumption that APCs deliver carethat is inferior to the care delivered by primary care physicians. In other words, looking to be associated with the “highest-quality” providers in the region, the health system had focused its alignment efforts on physicians to the exclusion of APCs. In contrast, independent specialist physicians in the region were well aware of the importance of APCs as primary care providers, because APC referrals represented a high percentage of their referral business (30 to 50 percent, based on interviews).
The Decision to Include APCs
The concerns raised about the quality of care provided by APCs, although unverified, posed a very real obstacle in NMHS’s decision about whether to include APCs in the formation of its CIN. In a few instances, primary care physicians saw APCs as competition and did not want them included in the network.
In the end, however, NMHS acknowledged the importance of APCs in delivering primary care in the region, and it determined that if the CIN’s mission was truly to elevate the quality of care in the region, it not only needed to include APCs in the network, but also required APC representation in the CIN design process. Thus, the name of the entity charged with developing the CIN was changed from Physician Steering Committee to the more-inclusive Provider Steering Committee, and a community-based independent nurse practitioner was elected to the CIN board.
With the framework for strengthening NHMS’s the historically weak alignment with APCs in place, the steering committee embarked on an effort to actively engage APCs to integrate them into the network. The CIN’s articulated goal was to become the “preferred partner for APCs” in the region. The initiatives and activities developed to achieve this goal formed the foundation of the CIN’s APC recruitment strategy.
For an independent APC to join a health-system-sponsored CIN, trust is required. Having an independent NP on the CIN board provided this important credibility. NMHS also engaged APCs working within its network to participate in recruitment meetings and phone calls as a means of building relationships.
To establish a single standard for high-value primary care across the CIN’s network, the CIN board created a committee charged with promoting and supporting such a standard in both physician and APC offices. This committee, called the Primary Care Collaborative (PCC) Committee, determined that, although similar processes could be used to promote high-quality care in the practices of both primary care physicians and APCs, special consideration was required to address the unique needs of APC practices.
For example, training for APCs differs from that for physicians, so guidelines and protocols should take into account differences in their approach to practices, such as possible differences in the indications for specialist referrals between the two provider groups. Similarly, each group’s unique needs and interests would need to be addressed in the design of continuing medical education programing in the content of the CIN’s newsletters.
One significant requirement for APCs in Mississippi (and in many other states) is that a certain number of patient charts must be regularly reviewed by the APC’s supervising physician. These physicians also are expected to provide APCs with guidance on patient care when needed. Although this supervision is mandated by the state, APCs pay for it, and based on APC’s responses to our inquiries, the cost and quality of the supervision they receive is highly variable and quality control of the supervision program is minimal.
To meet the needs of APCs in the CIN, the PCC Committee established a supervising physician program, which APCs can access for a set price to receive the state-mandated level of record review. More important, this program also provides a means for creating strong working relationship between APCs and supervising physicians. By promoting clinical mentoring, easy phone “curbside” consultations, and record-review feedback, the program aims to create a virtual patient-centered medical home that will elevate the quality of care delivered across all CIN primary care locations.
In sum, faced with a shortage of primary care physicians in its region, NMHS has embraced APCs as primary care providers within its CIN, with the goal of enhancing the quality of care for people living in its service area. NMHS’s decision reflects an increasing awareness among CINs of the key role APCs can play as essential primary care providers, in a trend that runs counter to a historical tendency among health systems to discount the value of APCs as lesser-trained providers not worthy of being included in CINs.
NMHS’s story has great relevance for future CIN development and population health strategy. Other health systems seeking to expand their primary care networks to effectively manage population health can take a lesson from NMHS not only in affording APCs a key role in the delivery of primary care but also in enlisting their participation in CIN governance and value-based contracting.