By Tammy Triglianos, DNP, ANP-BC, AOCNP, Ethan Basch, MD, MSc, FASCO, and Matthew Milowsky, MD, FASCO
Not only are the number of advanced practice providers (APPs) practicing in oncology continuing to increase, but the role of APPs caring for patients with cancer continues to expand. APPs have significant roles in providing continuity of patient care in oncology, from managing complex cancer regimens over time, supporting enrollment on clinical trials, addressing survivorship needs, symptom management, and facilitating end-of-life care.
Effective collaboration between APPs and physicians is key to providing high-quality care for this complex patient population. Setting expectations for the care team from the beginning can help all parties understand the APP’s scope of practice and the important role the APP plays on the team. To ensure continuity and consistency in communication within our team, we created a standard of practice and distributed it to providers at our institution; when new APP/physician teams are established, the document is shared with both parties. The overarching goal is to empower our APP/physician teams to be set up for a successful team-based care collaborative practice.
Feedback received from a physician and APP team describes the value in receiving this guidance from the outset of their collaborative practice. This team reported that the guidance provided invaluable information to understand what is and is not included in an APP’s scope of practice. Both the physician and APP explained that the document provided a framework to create a collaborative working relationship toward improving efficiency in the day-to-day team-based patient care. One physician who has worked in parallel with APPs for many years reported an improvement in the overall working relationship when employing this document in practice. For example, with the suggested use of alternating APP/physician visits, the APP/physician team reported that such a strategy helped balance their patient schedules such that there were fewer overbookings as well as less template underutilization. They also felt that alternating visits allowed for both team members to establish relationships with patients and set important expectations around team-based care. Additional feedback received suggested that the document helped create an environment of teamwork and autonomy for APPs.
To help other APP/physician teams set and clearly communicate roles and expectations, we are sharing a template version of the standard of practice we created and utilize in our institution. You can read it below, or download an editable document. We hope that other teams will use and adapt this document to meet their needs and improve the delivery of team-based collaborative cancer care in their own practices.
Division of Oncology Guideline for Advanced Practice Provider/Physician Collaborative Practice Model
The vision for the Advanced Practice Provider (APP)/Physician Collaborative Practice Model is to deliver empathetic, state-of-the-art, best-quality patient care using a team-based approach with a commitment to support diversity, equity, and inclusion in all aspects of the practice. This collaborative team-based approach to patient care will be cost-effective, ensure accountability, and allow the APP to perform at the highest level of their competency and training.
The (STATE) Board of Nursing (BON) Collaborative Practice Guidelines serve as the foundation for the Division of Oncology APP/Physician Collaborative Practice Model to ensure that all aspects of the model are consistent with the tenets set forth by the (STATE) BON and Medical Board.
Advanced Practice Provider Role and Responsibilities
The APP with the supervising physician will have a major role in clinical decision-making and will work to support the disease-specific health care team including the nurse navigator, nurses, certified medical assistants, scheduling and other administrative staff, the research team, and all other individuals involved in the patient’s continuum of care to ensure that the patient is able to seamlessly navigate the comprehensive array of oncology care services within the health care system. The APP may serve as a point of contact for the disease-specific multidisciplinary oncology program to assist with the appropriate triage of new patients and complex cases. The APP will conduct patient visits and collect and document patient-reported histories in the electronic medical record, perform physical examinations, order and interpret laboratory, diagnostic, radiology, and other studies, conduct diagnostic and therapeutic procedures (as per training and formal competency evaluation), prescribe medications and other interventions, and utilize advanced critical thinking skills to formulate diagnoses and treatment plans. The APP will serve a major role in the education and management of treatment-related side effects, survivorship care, and psychosocial interventions. All roles and responsibilities will occur in collaboration with the patient’s treating physician.
The clinical practice for the APP will include an independent clinic schedule and clinical duties that align with their designated clinical FTE per the job description utilizing the oncology template standard (i.e., 4-hour clinic session). The APP and physician will work in synergy to promote efficient clinic flow. The APP will review and respond to electronic medical record in-basket messages daily on workdays. The APP will be available for clinical issues throughout the workday. Procedures for missed clinics including clinic cancellation will be guided by the (INSTITUTIONAL) policy, a system-wide initiative to improve operational efficiency, enhance the quality of (NAME OF INSTITUTION) system processes, and strengthen financial stability. All coverage for patient care including electronic medical record in-basket and paging when out of the office will be performed by a licensed provider of at least equivalent credentials.
The APP can prescribe pharmacologic and non-pharmacologic therapies as per the (STATE) Collaborative Practice Guidelines and (STATE) Medical Board, including controlled substances schedule II-V. All prescriptions will include the patient’s treating physician’s name as per Collaborative Practice Guidelines.
The APP may serve as an authorized prescriber of antineoplastic treatments for subsequent cycles or dose modifications of any antineoplastic agent (oral, parenteral, or topical) after completing the antineoplastic privileging process. The attending physician is responsible for initial approval of the treatment plan and signing cycle 1 day 1. This prescribing authority must be approved by the Chief of the Division/Chair of the Department employing the APP and approved by the Credentials Committee.
The APP will maintain credentialing and certification requirements per the (STATE) BON or (STATE) Medical Board guidelines, including 50 continuing education credits per year. The APP will also complete a monthly TimeTrex with designation for specific practitioner versus RN work.
Quality Improvement and Professional Development
The APP will engage in regular continuous quality improvement by suggesting and implementing improvement measures and serving on improvement projects as requested. The APP will engage in professional development through developing excellence in specific areas of interest including education or mentoring, research, quality improvement, community outreach, or clinical activity. Oncology specialty certification is strongly encouraged.
APP/Physician Clinical Collaboration
New patient visits will be performed by the physician or by the APP in collaboration with the physician with the establishment of a diagnosis and treatment plan. At the initial patient encounter, the patient and caregivers will be introduced to the treatment team and the collaborative practice model to appropriately frame expectations. Return visits will alternate between the APP and physician as determined by the disease-specific team. All visits to discuss restaging scans/response assessments will occur with physician involvement.
The APP will document and bill clinical activity as an independent provider or as a shared service visit within 72 hours of the patient encounter as per institutional guidelines. For shared visits, the APP and the physician must have a face-to-face visit on the same day with the patient and both must document their portion of the visit. It must be medically necessary for both providers to see the patient.
Quality Improvement Process/Performance (APP/Supervising Physician Meeting)
Every six months a meeting will occur between the APP and supervising physician to provide an ongoing review of care provided for one or more frequently encountered clinical problems. For newly appointed APPs, meetings between the APP and supervising physician will occur more regularly (monthly for the initial six months), followed by at least every-six-month meetings thereafter. The APP will maintain appropriate documentation signed by the supervising physician.
Code of Conduct/Working Relationship
The supervising physician and APP will have a mutually respectful professional relationship characterized by effective communication and the highest ethical standards including a commitment to honesty and integrity with a shared goal to provide exceptional patient care. Professional conduct will conform to the (INSTITUTION) Professional Conduct and Ethics Policies.
For questions or concerns regarding role, responsibilities, or APP/Physician Collaboration, contact the Division APP Lead. For any unresolved situations, contact the Clinical Vice Chief.
Ms. Triglianos is a certified oncology nurse practitioner at The University of North Carolina, NC Basnight Cancer Hospital. She is a member of the ASCO APP Task Force. Disclosure.
Dr. Basch is chief of oncology and physician-in-chief of the cancer hospital at the University of North Carolina. He is a member of the ASCO Board of Directors. Disclosure.
Dr. Milowsky is a medical oncologist and section chief of genitourinary oncology at the University of North Carolina at Chapel Hill. Disclosure.