So, leading up into this talk, the real basis for success in this space is the true collaboration and partnership. So, my charge here is to speak to the APP Physician Collaborative Relationship with an aim to provide high-quality care. The objectives of my lecture are to highlight the value of the GI-APP partnership, GI-MD and APP partnership, describe the team concept, really. This is one area where the team concept really comes to life and needs to for success. Discuss the strategies for successful collaboration. These recipes have been now quite well-defined, and Sarah actually showed you a recent piece that came out in a major journal. And then finally, summarize with some pearls and caveats. The APP Physician Collaborative model really is born out of necessity over the last several years. Sarah again mentioned some of the landscape that exists currently, especially in the post-pandemic era, with regards to access, you know, the combined procedural and cognitive nature of our practices. So, I think that there is definitely an unmet need that this model fulfills and is one of the main reasons that it has been very successful as well. However, the partnership, any partnership, requires mutual trust, respect, and true collaboration. Typically, outside of the concept of partnership, there are some collaborative formal agreements in place. These do include the scope of the clinical practice and the various aspects and attributes of the APP's role in a particular practice. Obviously, there's no margin, there's no mission, so any such model should be financially feasible. And then, it's really important to note that all these caveats need to be fulfilled for a long-term relationship to be successful. This is an example of a form. This is from our own institution. This is a collaborative relationships attestation form where you have a nurse practitioner who is collaborating formally with a physician. And a similar construct exists for the PA group as well, and different entities have different ways of putting this in place. And this just kind of formalizes the relationship a little bit and allows for the periodic reviews and appraisal of the relationship at the granular level. A couple of slides to talk about the other important aspect of any collaboration, especially in modern times, is the concept of liability for APP work, both good and malpractice work. So vicarious liability talks about the fact that the physicians may be held responsible for the acts or omissions of whoever they are collaborating with or supervising and or working with. In this case, it happens to be the APP group. Negligent supervision refers to the fact that the physician doesn't physically need to be present or consulted, they just must remain available and participate in the services as they're needed. But that umbrella, that relationship needs to be in place for that construct to be successful and to be validated as well. Negligent hiring refers to the concept that the physician may still be held responsible if they willfully and knowingly hired a partner that was not up to competence. The most common malpractice claims, and this is a sensitive topic, but there's a fair amount of experience in this, dealing with this at various levels. It's important to note that while most of us will practice at the maximum extent of our licenses and our abilities, there are some issues that come up every so often, and these are related to primarily these elements, which is inadequate supervision, untimely or delayed referrals, and this is true across the spectrum. This could be providers at the MD level or APP level, but these are not looked upon well, and they do come up here every so often for reviews. An improper diagnosis, whether it's a cognitive-based consultation or a procedural diagnosis, insufficient examinations, certainly in the case of a shared visit, which I'll show later on, a shared office visit needs to have proper documentation and performance. Misrepresentation of facts and fraud, of course, are not common, but they should be kept in mind and one would be held liable for that. Now, so how do we, keeping in mind these liability issues, how do physicians and APPs, how do we mitigate these issues and keep them to a bare minimum or eliminate them completely? So it's important for practices and physicians to check the APP credentials and references. I can't tell you how important it is when we do this to make that phone call, to check with the previous employer and do our level best due diligence to figure out if this is the right person for the practice. At the leadership level, it's really important to know what the state and federal and institutional policies are and then, of course, develop literally binders and or orientation manuals, as was referred to earlier, to define the scope of practice and then move on to the orientation onboarding process in a very formal manner and stepwise manner that Sarah demonstrated. These days, these weeks, these early months are really critical to set the APP up for success. And obviously, with the collaborative agreements in place, as I referred to earlier, there is a need for keeping performance reviews in place and upgrading them and adjusting them flexibly as time goes on. The importance of documentation is important, especially in the early years when the APP's capabilities, scope of practice is being assessed and they are incorporated into a practice. And then ongoing compliance monitoring is obviously very important. So the case for the collaboration is really clear. The national landscape for GI access is really difficult and increasingly difficult, especially in the post-pandemic era. And it really is a testament to the capability, the might and the prowess of the APP group to allow these intakes for these referrals, new referrals, as well as follow-ups that were backlogged in the last three years or so. So that's a huge portal of entry for any practice. In addition to that, APPs can certainly help with improving clinical and ancillary testing, which we'll talk about a little more down the road. And really, integration of APPs into practice at the very basic level does allow physicians to focus more time on endoscopy, which of course does take over the majority of the physician's time as well. In addition, inpatient APP models, such as the one we have had for several years at our institution, they allow for timely consult delivery for sick patients who are in-house, especially nowadays, and they really promote interdisciplinary collaborations and communication, improve patient satisfaction, all these metrics that are important for an institution to be successful in the era of value-based purchasing. A reduced burnout case has been made, and I will hear more from Dr. Bikari next on that topic. But I do believe and I've always felt that the APP Carter actually really bridges a critical gap that has always existed in American medicine between nursing and the physician group. The APP team-based model has the capability of billing independently for services, participate in shared visits. We'll look at some models next, provide both inpatient and outpatient care, and really do some of the non-endoscopic work in a practice that is critical, phone call, responsiveness to patients, communication with families, following up on results, and bringing that back to the team, to the pod, and ensuring that the machine remains well-oiled and that care is delivered in a seamless manner. Obviously, as folks like Sarah and many others have shown, is that they can really participate meaningfully in education, clinical research, and training, and really furthering all the missions, both in academic as well as private practice settings. The team-based model can also provide excellent care to follow-up patients. The physician focuses on some of the more complex consults and issues, and not to say that an experienced APP can also handle many of the complex issues as they grow and become more specialized in their particular roles. The interpretation of ancillary testing and performing motility testing and so forth, HCV treatment clinics, all of these are very tangible examples of what the APPs can bring to a practice, regardless of a setting. Now, in some cases, this has been a topic that has been discussed and may become more important in the years to come, is the performance of endoscopy by APP colleagues, and that's something we can talk about as well over the next two-day period. So what are examples of meaningful collaborations? Because it's nice to talk about the concept, but here are some of the elements that can be easily put into place. High-quality clinical practice models, such as the paradigm that I just discussed. Training of junior APPs and training across the board, both for themselves as well as for their junior colleagues. Acquisition of new skill sets, such as those in motility interpretation, breath testing, other types of ancillary testing that occur in most GI practices. Technical development has been a huge part of our lives here at the University of Rochester, as well as in other places, where you really need to look at the team and say, how does each member progress, whether they're in academic or private practice settings, and really feel gratified that they are in a role that is continually moving them forward and upward, so that they can look back after years of practice and a career and say, I really performed at the highest level of my skill set. In many cases, leadership roles do emerge from time to time, and again, I refer to Sarah who recently was added to the Department of Medicine leadership as the lead APP for medicine, which is a high honor. In all of this, I think the support from the institution, the support from the practices, the support from an encouragement and championship from the physician partners is critical, and it boils down to small things such as CME support and all the way to promotions and such. The practice model, a couple of slides on that, the most common type of practice model in collaboration is the outpatient practice, but several examples of inpatient delivery as well out there, and in many cases, it can be outpatient and inpatient. Again, all the attributes of this collaboration have already been identified, and they will be there on the enduring material. Different types of models exist, which is the shared outpatient visits, which we have a lot of. Other models have where you have the physician seeing the new patients and the APP seeing the follow-ups, hybrid models, and in some cases, the APP is only seeing the inpatients whereas the physicians are focusing on outpatients. No model is better or worse than the other one. It just depends on what your practice is. Now, the other aspect of the day-to-day workweek that is important is the divide and conquer strategy, which is the APP has defined tasks and roles. The physician has similarly different roles that they perform to the maximum capability of their license. Again, the idea here is to improve access to keep a streamlined throughput and enhance the patient care quality as well as the overall patient experience. A couple of lines on the billing and reimbursement issues that do come up from time to time and actually we do need to pay attention to. Medicare reimburses independent APP services at 85% rate of the Medicare fee schedule for the physicians. Again, as Dr. Vicari mentioned and Jill mentioned, the documentation and the appropriate billing and coding is really key to support the financial side of the practice model and allow the non-financial aspects to really flourish and develop. The shared and split service model is something that we've had a lot of experience with. This is a clinic visit where the APP and the physician see the patient together. These documentations have just recently changed a little bit in that the 2022 attestation burden for shared visits is based on medical complexity, but there still needs to be a separate note. We expect some further changes to this in the next year or so where it will become a little bit more time-based billing. The incident two billing has been there for a long time. It is a model where the reimbursement really approaches the 100% mark and these are the requirements for the incident two billing process to take place successfully and meeting the legal requirements. The physician must be seeing the patient initially and be available for consultation and must remain involved for the course of the treatment. This one is a little bit more of a high red flag or audit setting where the federal government does look at these models a little bit more carefully and make sure that people are following this. This is for non-hospital clinical-based services only, outpatient setting. These are some of the reimbursement rates in a table form. This is the independent billing at 85, shared and split, and incident two approaching 100%. So the key principles really, after all of this, for successful collaboration are defined on this slide. There needs to be a physician group and a whole system buy-in to the concept of the APP playing a huge role in practice. This is the concept of perceived value. We've talked a lot about this and this is applicable to everybody. It's applicable to the most junior partner in a practice or to a fellow in an academic setting, to nurses in the endoscopy unit. There has to be a perceived sense of value and that's important for physician leaders and institutions to realize. The APPs must definitely fulfill an unmet need and that is the primary role and responsibility and other roles follow. And in most cases, as it's becoming pretty clear, there are significant unmet needs in clinical practice. The concept of trust, respect, and partnership has to be there. A team-based approach is important. And without that, it's very difficult to set us up for success. Now, one thing that I've paid a lot of attention to over the years is the concept of fair compensation, regardless of what level you are in the practice. And that's important, not just for the salary, but the benefits, CME support, time off, and increasingly in the modern era, attention to all the other needs that providers have in terms of family time, paternity leave, and so forth. This is really a key area of attention that's grabbing the imagination of a lot of progressive practices and something to keep an eye towards if you want to retain the best people. Professional development is a huge part of this whole discussion, and we can talk a little bit more about that in the Q&A session. So again, just reiterating the factors that determine successful APP integration into practices. These articles have been published very well. I encourage you to look at this article, which really defines a lot of these principles. So in a graphic form, the APP Physician Partnership really is a multilateral, multi-pronged effort. I think it really starts with the buy-in, the perceived value, the inclusion in practice discussions. That's really key. These discussions, these two-way partnerships need to be open, constructive communication efforts on both sides. The name of the game here. But at the same time, and again, this is applicable to all members of the practice, clear performance expectations and providing support for where the APP colleague needs help and or needs to raise the bar wherever applicable. This is important. I think without that, it's difficult to define metrics of growth. Professional development opportunities are really key, and I find that in a majority of cases where these partnerships are not as successful as one would like them to be, it is for these reasons where there is no attention paid to growth, development, and just career enhancement at the basic level. Periodic performance reviews, you can determine the timing of it. Sometimes they need to be a little bit more frequent. Other times, a lot of it is autopilot, and you just review these, especially with experienced colleagues, but some form of structure needs to be in place. Assistance with conflict resolution. In my days of chairmanship of the department, this is a regular feature at the leadership level, and these issues do come up because we are all humans. And increasingly in the pandemic, one has had to deal with a lot of these interpersonal things. But these do come up both on the personal side as well as on the professional side. And I think addressing them in a timely manner with the principles of fairness, objectivity, and compassion is really key. Without that, I think the employee, the colleague, the associate does not feel valued and feels somewhat short-changed. So that's a really, really big one, especially I'm speaking to the leaders of practices. Successful collaboration through professional development. I've already talked about a lot of different platforms exist. And again, leadership opportunities, simple things like QI projects, engagement with trainees in an academic setting, engagement with junior partners or other colleagues in a private practice setting. Really small things that lead up are the building blocks for bigger things to come for a particular career. Again, scholarly activity is important. I have always tried to champion that. I think it's important if you even present one abstract, one paper, one review article, get your name on these tangible products that are out there for posterity. People around the world will look at it on the internet, read them in journals. I cannot overemphasize the importance of this, regardless of the setting, whether it's private practice or academics, or even smaller practices. It's really important to develop these skills and spend time doing that, even if it's at a smaller level. And then one thing leads to another. Now, community engagement is really key. We are very fortunate in upstate New York to have a lot of active chapters, ranging from the Crohn's and Colitis Foundation, all the way through the Pancreas Cancer Association of Western New York, and many others. And a lot of our nurses and our APPs and our physician colleagues are engaged very actively on some of these annual events. And this really provides them a platform to engage with the community and bring their intellectual and cognitive capabilities out on the street, where they can engage with patients and family members, in many cases, some of their own patients, and disseminate that awareness and education, which is also part of our mission. Sarah beat me to presenting this article. But this is a recent article that came out that really defines some of the key principles, and I would encourage you to look at that in your time. So finally, here are the practice pearls. APP Physician Collaborative Model has tremendous value. Value is a key word. It has significant potential and a huge promise. And I think, for me, that is a key takeaway statement from this lecture. And from this concept, tremendous potential, a lot of promise, a lot of it is still untapped across the board. The practice buy-in and the mutual trust and respect that needs to be in place is really key, because that generates a sense of value. A sense of value is important not only at home, but also in a professional practice setting. And without that, it's really difficult to retain good people. Strategies for successful collaboration have been defined in work that we've presented, as well as others. And that really needs to be looked at and be part of a binder for most practices that are looking to do this. The clinical practice collaboration model has been prevalent for a long time. The key tenets there are that, based on federal guidelines, these documentation and billing burdens and requirements keep changing from time to time. Be aware of those and do them to the best of your ability so that you stay above the fray in that case. And collaboration certainly can be extended to patient education, clinical research, scholarly activity, and overall professional development. And that is really the key to success for a long-term relationship. Thank you very much. Thank you.

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