So this is again, thanks to the course directors for asking me to speak once again on one of my favorite topics, which is the APP MD collaborative relationship, providing high quality care. So here are my disclosures. The objectives of this talk is to highlight the value of APPs in GI practice, describe the APP physician team concept, and discuss some strategies for successful collaboration across all practice settings. And then of course, summarize with some pearls that I have gleaned over the years. So the APP collaborative physician collaborative practice model is a model that's born out of necessity. As we heard, necessity is the mother of invention, right? So that really applies here broadly. You know, this model has helped us, you know, enhance access, especially in the pandemic. You know, the procedural nature of GI requires somebody on the ground to kind of, you know, take helm of the ship and keep contact with the patients. Of course, it does require a mutual trust and respect and partnership that does take some time to develop, but it's a founding cornerstone of such a model. Typically most places will have some formal collaboration agreements in place, which I'll run through really quickly. And then of course, the scope of the practice for the APP can include clinical practice, education, clinical research, as we just discussed briefly, and in some cases, procedures as well when we are aware of that, the national landscape. Now there's no margin, no mission, that definitely is a true statement. But so on those lines, these relationships, these models, these practice paradigms definitely need to be financially feasible and make sense overall to the business enterprise. But I do believe, as I will show you hopefully, and you'll see throughout this course, that long-term very meaningful and successful collaborative relationships and partnerships are possible. So as I mentioned, some of the formal structured collaborative forms are in place. These are fairly well laid out in place by state regulatory bodies and institutional bodies. Here's an example of an NP form for New York, and here's another one for the PA side of things. This is specific to our hospital. And these are in place somewhere in a file and kind of formalizes the relationship that state and institutional bodies may require. And there is a periodic review process that it connects with as well to make sure that both parties are performing their respective duties as such. Now a couple of slides just to talk about the important aspects of such a relationship or partnership. There is an element of vicarious liability for the physician, which means as a supervising or collaborating partner, the physician may be held responsible for the acts or omissions of the APP, which further actually is a very important incentive for both parties to always perform at the best practice level and stay out of trouble when it comes to clinical medicine. Negligent supervision is a legal term where basically the physician doesn't need to be physically present or consulted, but they must remain available. But it's negligent if you're not available and you're not providing that level of partnership. And of course, negligent hiring does not need too much definition. I think if somebody is not up to par, the interview process will likely weed them out automatically. Most common malpractice claims, this is again a topic that's not commonly discussed, but in the physician APP partnership realm, these are the issues that usually come up. Inadequate supervision is number one. And this usually starts as the APP really looking forward to or having a very basic expectation of running a practice either independently or in collaboration with the physician, but that the physician not necessarily being available or providing optimal oversight. So that's an unacceptable situation that presents risk for both individuals as well as for the practice. Untimely and delayed referrals, now where APPs are involved with a referral triage, as they are in our institution as well, that becomes important for the APP to really pick out the urgent and emergent consults and prioritize them on top of the deck. Improper diagnosis is a little bit less common because most of the cases that the APPs are evaluating, especially with time and experience, especially where procedures are involved and the physician is very intimately involved. I think between the both of them, they'll probably almost always come up with the accurate diagnosis. So that's a bigger problem for the proceduralist or the endoscopist where missed cancer or complications or some type of a less than optimal outcome is a little bit more common compared to that for the APP. Insufficient examination and documentation is an issue. We'll talk about that in the discussions. Misrepresentation and fraud, of course, are not expected and are a different level of problem that I won't go into right now. Mitigating risk strategies for physicians are listed here. Obviously, you need to vet your candidate, whoever it is, whether it's a physician or a fellow or an MD, really know your state and institutional regulatory construct. And then something that Sarah alluded to is the onboarding of the new APP and providing the initial mentorship, guidance, support, encouragement, motivation. It really takes six to 12 months for a sub-sub-specialty APP to gain that level of proficiency. And then, as I mentioned, the collaborative agreements really speak to the importance of performance reviews and the importance of documentation and quarterly, semi-annual or annual reviews, whatever the case may be. And of course, I already made some of the case for the APP-physician collaboration, but here are some of the data points from national data. The GI physician shortage continues, and especially in the post-pandemic stage, it is really almost achieving crisis levels. There's a lot of attrition in the GI workforce and access is an issue. Nursing staffing has gone down. Endoscopy units have rooms closed still. And this is well reflected in the data. So I think this is not for good reasons, but for those reasons, especially a more important time to invoke the APP paradigm even more than we were doing in the pre-pandemic area. And these access and partnership-level patient care enhancements are applicable both in the outpatient as well as in the inpatient setting, such as we have established and we can talk about in the discussion portion. So the APP has really, in my mind, helped bridge a very critical gap, even between advanced nursing and physicians, where they are independent providers, and in time, they become really, really good at what they do. The team-based model is listed here for the APP and the physicians. Here, it involves everything from independent billing to shared visits, and then facilitating patient management outside of the endoscopy unit. I refer to the inpatient service skill set, and of course, education, training, and clinical research, which we will emphasize throughout this course, and I believe is a huge part of making an APP successful, regardless of the practice platform. Examples of meaningful collaboration are listed here. I really believe that any collaboration, whether it's research or training or education, really needs to be a meaningful, productive, and engaging partnership. If it's not a win-win for both parties and for the practice, it becomes difficult to sustain that over time. So it all starts with our patient. We are here for the patient primarily, and a successful, high-quality clinical practice really sets the stage for other things to come, whether you're training for ancillary procedures, breath tests, or anything else you're requiring, knowledge and new skills, you're participating in research, enhancing your professional development. These are all very good examples of meaningful collaboration. Of course, the practice and the physician champions and institutions have to provide the opportunity, the resources for the APP to do all of these things, or at least participate in some or more of these activities. And as someone said to me a long time ago, it's very hard to just live on love and fresh air, right? You do need the money, you do need the time, and you do need the support. And last but not the least, I think leadership roles are really very, very important. And Sarah can speak to it, and others on this course, or faculty, is that once you achieve a leadership status, even though it's a smaller role or an intermediate role, you realize what the devil is in the details. And you become so good at what you do just by assuming those responsibilities, and then looking at the problem from another side, the other side of the table, and then you become even better as your original clinical provider status mandated. So in the practice model, of course, we have a different type of experiences. We have the outpatient, inpatient, and a mixed experience as well. We can speak to that later. But the overall emphasis here is increased access, and continuity, and timely follow-up, as well as facilitating communication with the patient and the patient's family. Now, the different models in practice are listed on this slide. This is a shared visit outpatient setting. This one here is the physician sees the NPVs, and APP sees only the follow-ups. I see that being very commonly employed in many practices. Including in our local and regional practices. And then, as I mentioned, some of the APP practices are inpatient, outpatient hybrids. They provide a real nice, diverse, and a nice mix of experiences. So it really does help break the monotony of just one type of the practice or the other. Then, of course, we are very well aware, just like our colleagues in primary care, we have many, many models where the APP is working independently. It has a collaborative agreement, but it's mostly working independently. And then we have experienced some success with the APP inpatient model, which we can talk about in the discussion. So the collaborative model really provides a clear division of tasks. I do believe that the divide and conquer strategy here is to be taken in a very, very positive connotation. And each person performs to the top of their license in the interest of the patient's care. This really does allow for delivery of good quality education and counseling, which has been one of the gaps even in American medicine, because the volume, we're constantly being asked to see more patients with less time. In my practice, particularly in my life, the coordination for complex care is really one of the jewels in the crown for an APP collaborative model. I cannot begin to tell you every day brings so many difficult patient scenarios that I could not even begin to touch that without the help of our navigators, our advanced nursing, and, of course, our APP partners. And obviously, all of that speaks to patient experience and satisfaction, which is being measured both on the inpatient and the outpatient setting. Final few slides will be on billing and reimbursement. We all know that the independent APP services are being paid at about 85% of the physician fee schedule at this time. And then the billing and documentation burdens are basically the same for each type of provider. But most certainly, if you are doing a shared visit, there are specific guidances in place that we do need to follow. But obviously, reimbursement will vary by payer, complexity, region, time, and so forth. This is not a simple equation. So the shared and split service model is detailed here. I won't belabor the slide. This will all be in your enduring material. But the model is frequently reviewed and is one of the higher level audit red flags. So if you're doing a shared and split service model in clinical practice, just make sure that you are following the compliance-based guidance. And there will be some changes coming to it. They were expected in 2023. It might still happen. But probably more likely 2024 when the E&M guidance will change a little bit more towards shifting the burden between the two partners. So more to come on that. But the incident two billing is listed here. This is something we don't do that often. This is a little bit more difficult to do right on a sustained basis. Requirements can be difficult to meet on a consistent basis despite the best intentions. So therefore, this actually is probably the highest level of red flag for audits by the federal government. And I think, in my personal opinion, should be resorted to only if there is no other option. The Medicare reimbursement APPMD model rates and types and rates are listed here. So 85% rate for the independent practice model. And then for the shared split model, 100%. And then incident two also 100%. But in this case, it's a complex equation to achieve that documentation and setting. So I would suggest that either we stick with the independent model or with the shared model. And both of these work very well. So finally, the key principles for successful collaboration are listed here. I alluded to most of them earlier in the talk. But just to reemphasize that there has to be a concept of perceived value in the system for this model to be envisioned and for this model to be supported and sustained over time. Without that perception of value from the institutional leadership, in my mind, it becomes difficult. And I think we have to champion that as physicians. We have to champion that as senior APPs. And that sets the stage for success. And I think the APPs definitely fulfill a significant unmet need in clinical practice, especially in the post-pandemic environment. But a lot of this success relies on trust, respect, partnership, and, of course, graduated training, experience, and escalating responsibilities in the system. The team-based approach, I believe, is very important for divide and conquer strategy. Especially in today's medical practice world, where there's so much coming at us. I will be remiss if I didn't mention that fair compensation benefits and perks are really important, not just to recruit the best talent to your practice, but also to keep them in-house and continue to invest them. Without that, I think it's become very difficult to retain people in general. And the professional mentorship and development we've already alluded to. And the factors that determine APP successes are basically more of the same and are listed on this slide, which you can refer to in the enduring material. But I think one concept that we have really, really found helpful is the concept of team-based care, where there is endorsement of this model, of this partnership at all levels of leadership, of physician championship, and so forth. And as I mentioned earlier, the importance of very careful, diligent, and meticulous onboarding, allowing the new APP the time to really learn the skill set, learn the craft, cannot be overemphasized. The investment that go in here is just like, I will use the analogy of raising a child in a family. You know, the first formative years are really very, very important to ensure that the person becomes a successful young adult. So again, some of the strategies that we talked about. There is one of the things that I personally like and I feel is very impactful is assistance with conflict resolution. This is once you deal with a problem together, you are best friends for a long time. And I think that in many cases, we kind of bounce off the effectiveness or efficacy of this conflict resolution from each other when we are dealing with difficult circumstances. Inclusion in practice discussions is important because without that, I think there is no voice at the table for the APP. And if you're working in silos as a leadership team and not including the APP, you're setting yourself up for failure, really. Open and constructive communication. There's a lot of emphasis in today's world on transparency, on constructive feedback, feedback in the moment. All of those principles apply here. I think anytime you are trying to develop a collaboration or a partnership that is not based on honesty, sincerity, and transparency, again, at some point, it will fail you miserably and it will not have been worth it. At the same time, I think both parties should have clear performance expectations of each other. And some of these are kind of written down in the bylaws and the collaborative agreement and so forth. But some of it is the spirit of the law and just being there for each other, being there to help out, understanding where the other party is coming from and being empathetic and sympathetic to each other's needs. I alluded to the professional development opportunities. These are my favorite. And they are hugely, hugely important in retaining good people and helping enhance their careers. So again, successful collaboration is professional development is a big one for me. Community engagement and relationships with other peers is important. And then the academic and scholarly part that we had a whole talk on today. Practice goals. The APP Physician Collaborative Model has a tremendous value, potential, and promise. And I think it represents one of the more innovative modern practice paradigms, at least in the United States. It is not a model that is in place in many other developed countries, even today. The key principles include practice buy-in, mutual trust and respect, and a sense of value and partnership. Unless there's a sense of value, this is not going anywhere. Strategies for successful collaboration I have defined in multiple slides and will be available to you. And there is some overlap, but some of the key principles have been well established. Clinical practice collaboration models enhance access and improve the quality of care and documentation and billing guidelines need to be adhered to. All the good that you do in the world, as we know from our early days in training, if you don't document and your billing and your documentation doesn't match up, again, you're setting yourself and the practice up for unnecessary trouble that you don't need. And of course, I do believe that collaboration can be successfully extended to patient education, clinical research, scholarly activity, and the overall professional development of the APP that is in your practice. So with that, I will stop. And thank you for attention. So we have, let's move this out of here. Key principles for creating a successful APP MD collaborative partnership are all of the following. Accept, so this is an accept question. So practice buy-in, mutual trust and respect, collaborative partnership, level of financial incentive, and APP professional development. So which one is not an important tenet? All right, so we have a practice buy-in. So it's an accept question. So practice buy-in is stated as maybe not that useful or important, but most people got the correct answer correct, which is the level of financial incentive. I think for a partnership and collaboration, the incentives and bonuses are not that important as the rest of them are. And I deliberately made it a little bit challenging because we know that we have a very, very smart group online today. All right, so the next question is all of the following are strategies which contribute to a successful APP MD collaborative relationship. Accept, so this is another accept question. So which is the wrong answer? So open, constructive communication, performance expectations, exclusion from practice discussions, because we want to keep everything a secret, and career and professional development opportunities. So which is the wrong answer here? Wow, so I think I win the early prize for a 100% correct answer from the group for my question, exclusion from practice discussions. I can tell you this is probably the number one reason that folks are dissatisfied and don't want to stay. And it is disrespectful. It is not contributory and is best avoided. So with that, I'll stop. We're already a little bit late. I'm sorry for that. But with that, I'll introduce Dr. Joe Vicari, who's our next speaker. And he will speak to work-life satisfaction and strategies for success. Joe, welcome. And thanks again for setting the stage up for this wonderful course.

APP MD collaborative relationship

advanced practice providers

successful collaboration

improving patient care

communication

shortage of GI physicians