Utilizing NP’s and PA’s in Long Term Care Practice

1. Utilizing NP’s and PA’s inLong Term Care Practice Marc G. Nevin, MD, CMD, FAAFP Long Term Care Medical Associates 4502 Starkey Road, Suite 9 Roanoke, VA 24018 540-387-9222 mnevin.ltcma@yahoo.com

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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 99300 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.

11. 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.

12. 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 – email record of all calls to all practice staff • Weekend – “Weekend Update” – Template to record all calls by facility and emailed to all staff • All on-call emails are retained in our computers

13. 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.

14. 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

15. Questions and Answers • Q&A • Further Questions – Call, Write, or Email • DrHovland • Angel Rivera • Dr Nevin

21. LTCMA - On Call NotesDates: • LGH – 776-4000 (4021, 4022, 4023) CRMH – 981-7000 • Back-up call - Dr Nevin : cell 520-9851 home XXX-XXXX • Provider: • NURSING HOMES • *CARRINGTON PLACE at BOTETOURT 966-0056 • Fri – pm • Sat - am • Sat – pm • Sun- am • Sun- pm • *FRIENDSHIP MANOR 265-2100 • (1N 265-2135 2M 265-2078 2N 265-2136 1W 265-2142 1S 265-2137 3M 265-2139 • 4M 265-2140 2W 265-2141 MW 777-4035) • Fri – pm • Sat - am • Sat – pm