Nurse practitioner and physician assistant transition to practice: A scoping review of fellowships and onboarding programs.

BACKGROUND: Newly graduated nurse practitioners (NPs) and physician assistants (PAs) benefit from transition-to-practice (TTP) support to move successfully into practice. Transition-to-practice programs (i.e., onboarding programs and fellowships/residencies) hold promise for improving workforce outcomes. PURPOSE: The purpose of this scoping review was to describe the literature regarding NP/PA TTP programs. METHODOLOGY: Using the Joanna Briggs Institute methodology, a specific approach for systematically conducting reviews, publications from January 1990 to May 2022 were included for review if they addressed fellowships/residencies or onboarding programs for NPs or PAs. Final data extraction involved 216 articles. RESULTS: The pace of publication increased over time, with a noticeable increase since 2015. Articles were most commonly about fellowships/residencies, NPs, and programs set in United States nonrural, acute care settings, and academic health centers. CONCLUSIONS/IMPLICATIONS: There is a gap in our understanding of onboarding programs and programs focusing on PAs, as well as TTP support in rural and primary care settings. In addition, there are few articles that assess TTP program outcomes such as benefits and costs. This review describes the need for more published literature in these areas.

NP and PA transition to practice: A scoping review of fellowships and onboarding programs.

OBJECTIVES: Newly graduated NPs and physician associates/assistants (PAs) benefit from transition to practice (TTP) support to move successfully into practice. TTP programs (such as onboarding programs, fellowships, and residencies) hold promise for improving workforce outcomes. The purpose of this scoping review was to describe the literature regarding NP/PA TTP programs. METHODS: Using the Joanna Briggs Institute methodology, a specific approach for systematically conducting reviews, publications from January 1990 to May 2022 were included if they addressed fellowships, residencies, or onboarding programs for NPs or PAs. Final data extraction involved 216 articles. RESULTS: The pace of publication increased over time, with a noticeable increase since 2015. Articles were most commonly about fellowships or residencies, NPs, and programs set in nonrural, acute care US settings and in academic health centers. CONCLUSIONS: A gap exists in our understanding of onboarding programs and programs focusing on PAs, as well as TTP support in rural and primary care settings. In addition, few articles assess TTP program outcomes such as benefits and costs. This review describes the need for more published literature in these areas.

Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study.

BACKGROUND: Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity. OBJECTIVE: To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes. DESIGN: Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA. PARTICIPANTS: Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017. OUTCOME: Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017. RESULTS: Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL. CONCLUSIONS: A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.

Physician assistant and nurse practitioner onboarding in primary care: The participant perspective.

BACKGROUND: Many new graduate primary care physician assistants (PAs) and nurse practitioners (NPs) can experience stress and difficulty as they transition to practice. Feelings of anxiety and role ambiguity are common and can lead to costly turnover, impact care continuity, and place patients at risk for poor clinical outcomes. Onboarding, the process of helping new hires adjust to social and performance aspects of their new job and has the potential to ease transition to practice for PAs and NPs. Recent research has linked PA/NP onboarding programs to increased engagement, decreased turnover, and higher clinical productivity. PURPOSE: To describe new graduate PA and NP perspectives of onboarding programs they completed in their first primary care position. METHODOLOGY: Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology. RESULTS: Analyses revealed nine thematic concepts that are described within two frameworks. Structural components include improving competence, training on the electronic health record, promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors include creating comfort and building self-confidence. CONCLUSION: Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs. IMPLICATIONS: These findings are beneficial to the health care workforce. Administrators can incorporate these findings into existing and future programs, and new graduate PAs and NPs can negotiate for the inclusion of these components in their first position.

PA and NP onboarding in primary care: The participant perspective.

OBJECTIVE: To describe new graduate physician associate/assistant (PA) and NP perspectives of onboarding programs in their first primary care position. METHODS: Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology. RESULTS: Analyses revealed nine thematic concepts that are described in two frameworks. Structural components are improving competence, training on the electronic health record (EHR), promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors are creating comfort and building self-confidence. DISCUSSION: The results describe and delineate important components for onboarding that administrators can incorporate into existing and future programs. CONCLUSION: Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs.

When is caring sharing? Primary care provider interdependence and continuity of care.

ABSTRACT: Efforts to improve access to high-quality, efficient primary care have highlighted the need for team-based care. Most primary care teams are designed to maintain continuity of care between patients and primary care providers (PCPs), because continuity of care can improve some patient outcomes. However, PCPs are interdependent because they care for, or share, patients. PCP interdependence, and its association with continuity of care, is not well described. This study describes a measure of PCP interdependence. We also evaluate the association between patient and panel characteristics, including PCP interdependence. Our results found that the extent of interdependence between PCPs in the same clinic varies widely. A range of patient and panel characteristics affect continuity of care, including patient complexity and PCP interdependence. These results suggest that continuity of care for complex patients is sensitive to panel characteristics, including PCP interdependence and panel size. This information can be used by primary care organizations for evidence-based team design.

Transition-to-practice programs for newly graduated advanced practice registered nurses and physician assistants: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to map the evidence on transition-to-practice programs for newly graduated advanced practice registered nurses and physician assistants, and describe how they differ. Additional objectives include summarizing what outcomes are evaluated and what gaps remain within the literature. By consolidating this information, health care administrators may more easily reference transition-to-practice methods to enhance their own programs for advanced practice registered nurses and physician assistants.z. INTRODUCTION: Transition to practice involves 2 program types: onboarding and postgraduate training. However, no existing reviews describe the state of the literature regarding these program types, and how they compare with regard to location, setting, and outcomes. Because transition-to-practice programs may improve workforce outcomes, understanding how these programs differ, and what gaps exist, is needed to help these programs grow. INCLUSION CRITERIA: This review will include articles describing transition to practice for advanced practice registered nurses and/or physician assistants, including onboarding and fellowship/residency programs. Articles will be included regardless of geographic location if they take place within a professional, clinical setting. METHODS: The scoping review will follow the JBI approach. Databases to be searched include MEDLINE (PubMed), CINAHL, Cochrane Central Register of Controlled Trials, Embase, ProQuest Dissertations and Theses, Scopus, and Web of Science. All included manuscripts will be screened by two reviewers and relevant data will be extracted. These data will summarize what transition to practice programs are used, how they differ, and what gaps exist.

Teaming up in primary care: Membership boundaries, interdependence, and coordination.

OBJECTIVE: Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks. METHODS: This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis. RESULTS: Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits. CONCLUSIONS: Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.

Emerging practices in onboarding programs for PAs: Strategies for onboarding.

OBJECTIVE: This is the final article in a series that examines the role of onboarding programs for new physician assistants (PAs) and NPs. On-the-job learning is highly relevant for this workforce. Here we examine the strategies organizations use to impart information and skills in onboarding programs. METHODS: In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Seven strategies were identified and are described in this article: Clinical mentoring, personal and professional mentoring, meeting with/shadowing other professionals, checking in by administrators, delivering didactic content, tailoring content or ramp-up, and assessing/ensuring competency. CONCLUSIONS: This article describes commonly used strategies in onboarding programs for PAs and NPs and can provide guidance to those designing their own onboarding programs. The programs we examined relied heavily on mentoring and other strategies appropriate for adult learners. Future work should evaluate the effectiveness of onboarding programs.

Emerging practices in onboarding programs for PAs: Program content.

OBJECTIVE: Healthcare organizations are interested in creating onboarding programs to assist new PA and NP employees as they transition to practice settings. There is a need for information on what the ideal content and topic areas are for clinics to include in their onboarding programs. METHODS: In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Eight content areas were identified and described in this paper: culture and values; goals and strategies; task proficiency; rules and policies; structure; working relationships; wellness; and navigation and politics. CONCLUSIONS: These common content areas may provide a starting point for organizations designing onboarding programs for their unique organizations.

PA job availability in primary care during 2014 and 2016.

OBJECTIVES: The objective of this project was to evaluate demand for PAs by examination of job postings. We compared proportions of PAs in primary care with proportions of job postings in primary care in 2014 and 2016 and described job postings for PAs by specialty in 2014 and 2016. METHODS: Internet job postings for PAs supplied by Burning Glass Technologies were evaluated for practice specialty. Job postings were compared with existing filled positions by specialty as reported by the National Commission for the Certification of Physician Assistants. RESULTS: In both years, more than 25% of PAs in practice were in primary care and fewer than 20% of job openings were in primary care. More than half of postings were in medical and surgical subspecialties. CONCLUSIONS: Our findings provide insights into which specialties have emerging high demand for PAs. The demand for PAs appears to remain much stronger for specialty jobs than for primary care jobs.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Emerging practices in onboarding programs for PAs and NPs.

OBJECTIVE: To describe administrative factors that should be considered when designing an onboarding program for physician assistants (PAs) and NPs. METHODS: Interview study of 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Five administrative themes are summarized: goals of onboarding, critical organization factors, organizational fit, designing the program, and costs of onboarding. CONCLUSIONS: Careful planning and administration are essential to the success of onboarding programs. Although onboarding programs must be designed with unique institutional needs in mind, the considerations identified by our project might serve as a useful guide to PA and NP employers in the process of creating an onboarding program.

Predicted shortages of physicians might even disappear if we fully account for PAs and NPs.

Healthcare workforce projections have important policy implications. Provider shortages can shortchange patients, and overproduction of providers imposes costs on society. The most publicized physician supply and demand projections, commissioned annually by the Association of American Medical Colleges, regularly predict dire physician shortages. These projections are based on unrealistically low estimates of the amount of physician work that can be replaced by physician assistants (PAs) and NPs. For example, the projections factor in the contribution of one primary care PA or NP as one-fourth that of a physician. If workforce projections used evidence-based productivity estimates, the predicted physician shortfalls would be much smaller and perhaps even disappear.

Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients.

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.

Primary care provider type: Are there differences in patients' intermediate diabetes outcomes?

Growing demand for services is leading primary care organizations to explore new delivery models. One approach incorporates multiple primary care providers on a team. Effective incorporation of multiple clinicians into teams requires well-defined roles, including the usual provider (who provides the majority of primary care) and supplemental providers (who provide a minority of primary care visits). Using data from the Veterans Health Administration, we examined whether differences in diabetes outcomes exist among patients with different types of primary and supplemental providers (physicians, physician assistants (PAs), and NPs). No clinically meaningful differences were observed based on the profession of the usual provider or supplemental provider, or whether physicians provided supplemental care to patients with PAs or NPs as usual providers. These results suggest that physicians, PAs, and NPs can perform a variety of roles depending on the needs of the organization and patient population.

Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study.

Background: Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. Objective: To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). Design: Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. Setting: 568 VA primary care facilities. Patients: 368 481 adult patients with diabetes treated pharmaceutically. Measurements: The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. Results: The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. Limitation: Most VA patients are men who receive treatment in a staff-model health care system. Conclusion: No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. Primary Funding Source: VA Health Services Research and Development.

Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data.

BACKGROUND: Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran's Health Administration (VHA) primary care patients with diabetes. METHODS: This patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a "home" VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations. RESULTS: Among VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75-0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07-0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69-0.97; reference least restrictive regulation). CONCLUSIONS: ICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.