Capturing APP Value: Industry Leaders Share Their Experiences

By Roger A Ray, MD, Akofa Bonsi, Michael Shenk, and Cynthia Bailey


APP Examples and Perspectives from the Field

We asked four APP executives to share how their organizations are truly unlocking the transformative value of APPs.


After years of hiring and expanding their advanced practice provider (APP) workforce, many healthcare organizations have not yet figured out how to appropriately deploy these roles to maximum impact. Health systems have a tremendous opportunity to elevate the impact of their APPs to achieve top performance.

COVID-19 has in many cases disrupted “business-as-usual” — helping to accelerate operational changes that were previously culturally difficult. Loosening of regulations, changes to reimbursement rules, and increased openness to change have led to shifts in how, where, and by whom care is delivered. Of all the rapid operational changes that have occurred during the pandemic, the increased deployment and effectiveness of APPs is one of the few with potential to fundamentally transform provider enterprise performance.

APP Leader Contributors:

Britney Broyhill,
Atrium Health

Rob Grabenkort,
Emory Healthcare

April Kapu,
Vanderbilt Health

Ruth Kleinpell,
Vanderbilt School of Nursing

Ben Reynolds,
University of Pittsburgh Medical Center

Corinna Sicoutris,
Penn Medicine

Susan Stempek,
Lahey Hospital & Medical Center

Strategic deployment of APPs allows organizations to more effectively match skill sets with clinical requirements and experiential demands of patients to create a highly specialized care model that reduces cost, improves quality, and enhances patient experience, while differentiating the organization from its competitors. In this way, capturing full APP value represents one of the few — and most powerful — levers healthcare organizations have to dramatically improve their performance across the dimensions that matter most to patients.

Achieving Top-Tier Performance

Appropriately positioned, APPs have continued to demonstrate their value and solidify their place in the provider enterprise. While individual situations will vary, we expect that as organizations continue to evolve their care models to meet the needs of patients, they should find themselves operating with significantly higher APP-to-physician ratios. While that may sound aspirational to many, a handful of organizations across the country already have figured out what it takes to unlock the transformative value of APPs and are forging a path that others can follow. Through a series of conversations, national APP leaders have shared with us the six key elements required to unlock the potential of APPs and achieve top-tier performance.

Six Keys to Unlocking the Transformative Value of APPs


1. Leadership Structure and Executive Support


Why It Matters

As with any transformative change, unwavering leadership at the top of the organization and strong partnerships with physicians are critical to unlocking the full potential value of APPs. Effectively utilizing APPs across the system often requires significant change to clinical and patient-facing practices and processes. Such change can be met with skepticism or resistance and requires investment (e.g., ambulatory space, additional care team resources). In our experience, a formalized APP leadership structure with a single point of authority and accountability for APP performance is key to achieving success.

Key Requirements
  • Executive leadership champion(s), who provide unwavering leadership and support
  • A formalized APP leadership structure with a designated leader who has single point of accountability

"Having in place a Director of Advanced Practice who has oversight for the APP practice model across the system and reports to the CMO has helped to create a strong partnership with physicians. In addition, adding APPs to the medical staff helped to ensure that APPs are always a part of the provider conversation wherever it occurs."

— Susan Stempek, MMSc, PA-C, FCCM, FCCP,
Director of Advanced Practice,
Lahey Hospital & Medical Center



2. Care Model Design


Why It Matters

To realize the full potential value of APPs, the care model must be designed to address patients’ needs, both clinically and experientially, with individual APP and physician roles designed to match their unique skillsets to those needs. Care models designed in this manner enable top-of-license practice for all providers and support efficient deployment of resources. Viewing APPs as providers as opposed to support staff with defined, predominantly independent roles across the ambulatory and inpatient environments is critical to the success of effective care model design. In the ambulatory environment, this often requires an APP having his or her own scheduling template. On the inpatient side, it might mean the service or patient is managed by APPs, and the APPs are empowered to do their own procedures with oversight by physicians as appropriate.

Key Requirements
  • Consistency and clarity of APP roles and expectations within the care model, designed to enable top-of-license practice
  • A commitment to providing the resources necessary to support the care model
  • Development of innovative care models that can position independent APP practice (e.g., telehealth, in-home care, on-demand care for episodic care, and hospital-to-home transitional care)

“One of the keys to designing care models that allow APPs to practice to their full potential has been to focus initially on areas where there is both a clear need for additional capacity and a strong sense of mission, such as in Pediatric subspecialties. These two elements help address any potential financial or cultural barriers. The successful redesign can then serve as a model to be rolled out to other services.”

“The other thing that has worked for us is engaging physicians in our APP subspecialty training programs. When physicians teach and train the APPs directly and see everything they can do and how great they are with patients, any initial resistance tends to fade away.”

— Ben Reynolds, MSPAS, PA-C, DFAAPA,
Chief Advanced Practice Officer,
University of Pittsburgh Medical Center (UPMC)



3. Alignment of Goals and Incentive Models


Why It Matters

It is critical that individual APP and provider group goals align with those of the health system to ensure all parts of the organization are pulling in the same direction and feel joint accountability for achieving targeted levels of performance. Well-designed incentive programs align goals and drive the behavior the health system needs to be successful. Consistency between physician and APP incentive models supports the partnership and team approach critical to effective care delivery.

Key Requirements
  • Alignment of individual, group, and health system goals with clearly defined targets
  • Well-designed and consistent compensation, expectations, and incentive models for physicians and APPs

“We have a universal compensation structure for all APPs that is aligned with physician compensation and incentivizes team-based care. For example, in the inpatient space, if the entire team is incentivized for patient experience, chances are high that the physicians and APPs will work effectively together to achieve targeted patient experience results. We’ve seen the needle move significantly on a lot of metrics when we’ve really incentivized team-based care.”

— Britney Broyhill, DNP, ACNP-BC,
Senior Director of Advanced Practice,
Atrium Health



4. Education, Training, and Professional Development


Why It Matters

As with most clinicians, APPs must receive focused training within their chosen disciplines to effectively provide high-quality care across the subspecialty-based environments of a health system. Likewise, organizational investment in the professional development and leadership skills of APPs is important to support active APP participation in management and decision-making and the creation of a robust provider enterprise leadership structure. It is also an important factor in successful recruitment and retention of top talent.

Key Requirements
  • Robust orientation and training programs
  • Investment in APP leadership and professional development infrastructure

“We have really invested in our APP leadership team and currently have a team of nine overseeing 300 APPs here. The investment in leadership training has really paid off — within two years of launching, our turnover dropped from 10 to 2 percent, engagement is off the charts, people have started joining our committees, and we’ve put teams together to keep pushing forward on measuring quality and impact to show the value to patients and the organization.”

— Corinna Sicoutris, MSN, CRNP, FAANP, FCCM,
Director of Advanced Practice,
Hospital of the University of Pennsylvania



5. Financial and Performance Management


Why It Matters

Without insight into the expected and actual impact of APPs, it is impossible to make fiscally sound and efficient decisions about their deployment and utilization within a care model. Reliable data and information about how many APPs are needed, where to deploy them, and how to measure performance and value to the organization (including financial outcomes, operational outcomes, and patient experience metrics) are critical to ensure effective decision-making. Ongoing monitoring supports a culture of accountability and continuous improvement while reinforcing top-of-license practice as a means to diversified generation of return on investment (ROI). Financial management can also help cut through the politics that often come into play with APP deployment decisions.

Key Requirements
  • A defined, analytically driven process for approval of new APP positions, which includes demonstrable ROI, accounting for all sources of value to the organization
  • Ongoing measurement and monitoring of performance with a defined value proposition

“We set standards to look specifically at which provider is seeing the patient, as opposed to the documenting provider, to ensure we are accounting for the work of the APP even when commercial insurers require that billing be done under the physician.”

— Ben Reynolds, MSPAS, PA-C, DFAAPA
Chief Advanced Practice Officer,
University of Pittsburgh Medical Center (UPMC)



6. Advocacy


Why It Matters

The regulatory environment and state-specific rules about scope of practice create a gating mechanism for how independently APPs can practice and how much transformative value they can contribute to the health system. Systems operating in states with more restrictive scope-of-practice laws can — and should — play an active role in advocating for policy changes in patient care delivery that increase overall healthcare value. Additionally, for systems that span two or more states, the potential for wide variation of rules within their markets can particularly constrain their ability to effectively deploy APPs to provide consistent high-quality, cost-effective, patient-centered care.

Key Requirements
  • Ongoing monitoring of regulatory changes that impact practice
  • A proactive role in advocacy at both the state and national level

“We have been working proactively with the state to increase understanding of the important role of APPs in patient care delivery and how updated state-level regulations and policies can support continued care model innovation to increase access to care and benefit our patients and communities.”

— April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN
Director, Office of Advanced Practice,
Vanderbilt Health


Pulling the Lever for Transformative Change

These six key elements successfully employed across the national APP leaders’ organizations are critical to unlocking the full potential value of APPs. Optimizing APP deployment and effectiveness is one of the most powerful levers to dramatically improve provider enterprise performance. The disruptive nature of COVID has accelerated broader deployment of APPs and more clearly demonstrated their potential value. Organizations must now intentionally hardwire these gains and leverage them as a catalyst for transformative change.

How Penn Medicine Is Optimizing APP Value

Tapping full APP value is dependent on building the right structure for the future. What does this look like? Penn Medicine shares their core elements and next steps for growth.

APP Leader Contributors


Atrium Health
Britney Broyhill, DNP, ACNP-BC,
Senior Director of Advanced Practice

Lahey Hospital & Medical Center
Susan Stempek, MMSc, PA-C, FCCM, FCCP,

Director of Advanced Practice

Emory Healthcare
Rob Grabenkort, PA, MMSc, FCCM,
Director Emeritus of the Emory Critical Care Center NP /PA Residency Program

Penn Medicine
Corinna Sicoutris, MSN, CRNP, FAANP, FCCM,
Director of Advanced Practice

University of Pittsburgh Medical Center
Ben Reynolds, MSPAS, PA-C, DFAAPA,

Chief Advanced Practice Officer

Vanderbilt Health
April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN,
Director, Office of Advanced Practice

Vanderbilt School of Nursing
Ruth Kleinpell, PhD, RN
,
Professor and Former President of the Society of Clinical Care Medicine


Learn More from the Authors


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© 2021 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.

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