Care and Quality Improvement Process for Advanced Practice Providers (APPs)
Advanced Practice Providers should implement structured care models focused on optimizing self-care capacity, coordinating multidisciplinary resources, and ensuring adherence to guideline-directed therapies to improve patient outcomes and reduce mortality. 1
Role of APPs in Quality Improvement
- APPs are instrumental in ensuring communication and longer-term adherence to guideline-directed medical therapy (GDMT), with evidence showing that practices with ≥2 APPs are more likely to use guideline-directed therapies and provide better patient education 1
- APPs demonstrate superior performance in certain clinical areas compared to physicians, including achieving better glycemic control, blood pressure management, smoking cessation counseling, and referrals to cardiac rehabilitation 1
- Nurse-led care models have shown superior outcomes compared to usual care by cardiologists for composite endpoints of cardiovascular death or hospitalization (14.3% versus 20.8%; hazard ratio, 0.65) 1
Core Components of APP Care and Quality Improvement Process
1. Collaborative Team-Based Approach
- Implement collaborative, multidisciplinary teams with APPs in central roles to provide care for people with chronic conditions and facilitate patients' self-management 1
- Ensure significant involvement of nursing, administration, laboratory, and pharmacy in quality improvement efforts for successful implementation 2
- Build partnerships between APP-led safety improvement efforts and those in other units or departments to enhance patient safety 2
2. Evidence-Based Practice Implementation
- Base care on evidence-based guidelines with APPs leading implementation efforts 1
- Create standardized clinical pathways and order sets for common conditions to increase guideline adherence 2
- Develop and implement patient-focused prescribing recommendations based on data collection from health systems 1
3. Care Coordination and Transitional Care
- Focus on optimizing self-care capacity and resource availability to support patients and families in independently managing their care plan 1
- Coordinate multiple health care team members, community resources, and family caregivers between health encounters 1
- Implement transitional care models targeting patients at hospital discharge to reduce 30-day readmission rates, improve care coordination, and medication reconciliation 1
4. Technology Integration and Data Utilization
- Utilize electronic health record tools to support quality improvement initiatives 1
- Implement continuous measurement of healthcare delivery using structural, process, and outcome indicators 2
- Collect data through mHealth applications to inform quality improvement in real-time and retrospectively 3
APP-Specific Professional Development Framework
1. Competency Development
- Define emergency care and specialty-specific competencies for APPs and require appropriate initial and continuing education 2
- Provide specialized training in patient education techniques, motivational interviewing, and cultural competence 4
- Implement standardized competency-based postgraduate training for APPs planning to practice in specialized areas 5
2. Professional Advancement Program
- Develop and implement an APP Professional Advancement Program to support all APPs regardless of their role and practice setting 6
- Recognize accomplishments and provide tools and resources needed for professional development and leadership 6
- Create opportunities for advancement, growth, and development of APPs across healthcare settings 6
3. Quality Improvement Process
- Establish a dedicated quality improvement committee with strong clinical champions to develop consensus on diagnostic and treatment pathways 2
- Include patient safety issues as the first agenda item at leadership meetings and provide performance metrics related to patient safety 2
- Implement a process for quality improvement with documentation and review of events and metrics to identify opportunities to improve care 1
Implementation Strategies for APP-Led Care Models
1. Patient-Centered Approach
- Assess social determinants of health including food insecurity, housing insecurity, financial barriers, and social support to inform treatment decisions 1
- Provide patients with self-management support from lay health coaches, navigators, or community health workers when available 1
- Ensure that responding clinicians have expertise in eliciting patients' goals of care and establishing treatment plans that reflect their wishes and prognoses 1
2. Continuous Quality Improvement Cycle
- Select performance measures based on strength of evidence, clinical relevance of outcomes, and cost-effectiveness of implementation 2
- Develop mechanisms to easily identify target patient populations and track quality metrics 2
- Conduct regular debriefing and measuring, recording/reporting of performance metrics as part of a rapid response system 1
Common Pitfalls and Challenges
- Insufficient information about how team members or interventions should be deployed for specific patient populations and clinical scenarios 1
- Lack of standardized diagnostic and treatment approaches leading to decreased quality of care 2
- Inadequate training requirements and support for new APP hires 5
- Variation in APP training and credentialing at the state level and by practice site 7
Evidence-Based APP Care Model Examples
- Nurse-led behavioral and medication management interventions have demonstrated long-term value in improving blood pressure over 18 months without significant increases in service use and expense 1
- Pharmacist-led models as core components of multidisciplinary teams with roles ranging from facility-level consultation to patient-specific pharmacotherapy optimization 1
- APP-led care in atrial fibrillation has shown superior outcomes to cardiologist care for composite endpoints of cardiovascular death or hospitalization 1