Utilizing NP’s and PA’s in Long Term Care Practice Marc G. Nevin, MD, CMD, FAAFP Long Term Care Medical Associates 4502 Starkey Road, Suite 9 Roanoke, VA

Language Counts “Mid-Level” Providers “Extenders” NPP – “Non-Physician Practitioners” or “Non- Physician Providers” ************************************ NP/PA’s

The Differences Between NP’s and PA’s Education NP – RN ->BSN -> MSN -> FNP/GNP/ANP/APN -> DNP PA – AA/BA/BS -> PA Licensure NP – combined Boards of Medicine and Nursing – independent license PA – Board of Medicine – practicing under the license of a physician

NP, PA and Physician Practice Models NP and PA work for the physician or practice In Virginia a Physician may have protocols with 6 NP’s and 6 PA’s NP has practice and “hires” collaborating physician In Virginia a NP must have a collaborative agreement/protocol with a Physician May have one or several collaborating physicians

Dangerous Generalization: PA’s are well trained to interview, examine, diagnose and treat medical conditions. NP’s are well trained to interview, examine, diagnose and treat medical conditions as they take care of patients and their families. A Rare Combination – RN, PA

Working with NP’s and PA’s What defines your practice is how you define your relationship with the NP’s and/or PA’s. The Relationship can be Loose or Highly Structured Styles of leadership The Boss NP/PA as Junior Colleague NP/PA as Colleague

Protocols, Guidelines, Expectations Protocols Keep it Simple Keep it Broad Keep it Vague What the NP/PA can do. Training/Comfort/ Competence Scope of Practice What the NP/PA cannot do. Physician sets specific limitations

Protocols, Guidelines, Expectations Guidelines This is where you can be very specific about what you want the NP/PA to do on a daily basis. The nuts and bolts of day to day practice. Admissions, visit schedule, medical records, dictation, coding, billing, etc. NP/PA to avoid facility issues – staffing, policies, billing, etc. Expectations Regulatory Compliance, Standards of Care, Practice Specific Expectations Continuing Education

Compensation Models Full-Time vs Part-Time Full-Time Salary & Benefits (Health, Dental, Life, Disability, & Malpractice Insurance; PTO; dues, fees, licenses; continuing education; 401K) Salary & Benefits & Some share of profits Salary & Benefits & Productivity Bonus Salary & Benefits Productivity & Benefits Productivity & Benefits & Bonus based on success of the practice

Compensation Models Productivity Share of Revenue Produced – Share of Practice Overhead – Benefits – Employer Payroll Taxes – Employee’s Taxes – Deductions = Paycheck Complex formula, variable paychecks Can be pooled and calculated every 3, 6, 12 months Simplified System Compensation fee schedule – for each series code set a fixed $amount to be paid to the NP/PA for each code submitted. Fee schedule determined by the Medicare/Medicaid Allowable Fees less 15% adjustment, less estimated overhead costs including all benefits (usually comes to 25-30% of expected revenue) NP/PA can easily track their productivity and pay. Insulated from practice management issues At risk for manipulation of visit codes.

Compensation Models All compensation models should account for the fact that the practice and/or the collaborating physician should be compensated from the NP/PA revenue for managing the practice, providing support, providing clinical back-up, and for assuming significant risk and responsibility.

Compensation Models On-Call Compensation Bundled vs Extra Compensation Our Model Weekdays 5pm-8am$ 60 Weekend Fri 5pm – Mon 8am$250 Monday Holidays $100 On Call Communications Weeknight – record of all calls to all practice staff Weekend – “Weekend Update” – Template to record all calls by facility and ed to all staff All on-call s are retained in our computers

Oversight and Support Chart Review Informal Formal Physician Support NP/PA needs to know that they may work independently as they feel capable, but the Physician is always available for consultation and support with patients, families and facilities.

Conclusion Physicians & NP’s & PA’s in Long Term Care Facilities Great Patient Care Great Facility Support Great Practice Model Great Financial Potential Great Partnership

Questions and Answers Q&A Further Questions – Call, Write, or Dr Hovland Angel Rivera Dr Nevin

LTCMA - On Call Notes Dates: LGH – (4021, 4022, 4023) CRMH – Back-up call - Dr Nevin : cell home XXX-XXXX Provider: NURSING HOMES *CARRINGTON PLACE at BOTETOURT Fri – pm Sat - am Sat – pm Sun- am Sun- pm *FRIENDSHIP MANOR (1N M N W S M M W MW ) Fri – pm Sat - am Sat – pm