 | Division of Gastroenterology and Hepatology University of Rochester Medical Center Rochester, New York |  | Division of Gastroenterology and Hepatology University of Rochester Medical Center Rochester, New York |
In the October issue, we highlighted multidisciplinary APP-based IBD clinics as part of our specialty clinic series and included valuable insights from four IBD-focused GI APPs as they reflected on their respective clinic structures, interdisciplinary collaborations, education, clinical trials and physician mentors. In this second part, our APP panel members share their advice for establishing successful IBD-focused specialty clinics. We also share the perspectives of two experienced IBD physicians who speak to the overall construct of their practice models, and reflect on their role as physician collaborators and the value of adding APPs to their clinics. We thank our APP and physician panelists for sharing their insights and experience and hope the pearls and caveats in this two-part series help our colleagues in their respective practices.
| P A N E L I S T S | |
|---|---|
 | Assistant Professor Schools of Medicine and Nursing Johns Hopkins University Baltimore, Maryland |
 | University of Rochester Medical Center Rochester, New York |
 | Alaska Digestive & Liver Disease Anchorage, Alaska |
 | Gastroenterology APP Clinical Supervisor Duly Health and Care Hoffman Estates, Illinois |
 | Professor of Medicine Director, IBD Center; Director, Fecal Microbiota Transplant Program Division of Gastroenterology and Hepatology University of Rochester Medical Center Rochester, New York |
 | Professor of Medicine Vice Chair, Division of Gastroenterology, Development and Philanthropy Emeritus Director, Program for Inflammatory Bowel Diseases Gastroenterology Division Department of Internal Medicine The Raymond and Ruth Perelman School of Medicine Perelman Center for Advanced Medicine Hospital of the University of Pennsylvania University of Pennsylvania Health System Philadelphia, Pennsylvania |
Ms. Enslin: It can be difficult to deliver a diagnosis of chronic illness to patients. What suggestions do you have for APPs who are discussing a new diagnosis of IBD with a patient?
Dr. Dudley-Brown: I wish I saw more newly diagnosed patients with IBD, as most are not given adequate information (or education) that IBD is a chronic disease. They may not always have control over symptoms, but they can control how they respond and act on it, learning what they can do to help themselves. Many IBD patients don’t even know what their disease is, or whether they have mild, moderate or severe disease, and how that is classified. Most patients who have had their disease for a while have developed resilience, so appropriately educating newly diagnosed patients can help bring a positive spin to hearing “you have a chronic disease” when you explain that there are mechanisms to deal with it. Empowering our patients with what they can do is extremely important.
Ms. Mohammadi: It can be overwhelming for patients to receive a diagnosis of a chronic illness. I recommend giving patients all of the information they need to know but also give them the opportunity to discuss it again and ask questions a few days later after they have been given time to reflect on their new diagnosis. I think a phone call a few days later lets the patient know you care and helps build trust and rapport between the patient and provider.
Ms. Heagy: First, start very basic. Research shows that your first two to five minutes in a life-changing conversation are the ones that will be best recalled. Be honest but stay positive. For example, “it is a good time for IBD care because we have new medications approved every year.” Second, bring the patient back often. Frequent follow-ups in the beginning are helpful since retention of information at the first visit is low. Finally, provide solid reliable online resources, such as the CCF (Crohn’s & Colitis Foundation) website. Caution against unregulated websites such as YouTube, blogs, etc.
Ms. Kearns: Recognizing the natural history of IBD, we know that several of our patients are diagnosed in early adulthood. In my experience, most of these patients are scared. One of the first things I do is acknowledge their feelings. I also ask what they know about IBD and what they would like to know about IBD. This really helps to guide our discussion during this first visit.
A patient is always going to remember the day they were told they have a chronic illness, so ensure that you are well prepared for this discussion. Provide an atmosphere that facilitates an opportunity for you to listen to your patients’ concerns and time to answer questions. I also provide patients and family members with information on membership to the CCF.
Ms. Enslin: What advice do you have for APPs considering establishing a similar specialty clinic in their practice? What challenges should they prepare for? What are some of the essential resources they should be aware of?
Dr. Dudley-Brown: New specialty IBD clinics and IBD-focused providers/clinics in GI practices are growing because of the increase in the number of patients with IBD. I see some new APPs frustrated by the variety of opinions on biologic usage due to the number of providers they work with. If possible, I would suggest that new APPs have only one to two other providers to learn from (ideally, one a physician and one an APP). If the goal is to be independent, then the APP needs to do a lot of their own education to be able to support their clinical decisions in practice, and this can take time.
There are a lot of online webinars on new therapies for IBD. The GHAPP (Gastroenterology & Hepatology Advanced Practice Providers) website provides on-demand access to presentations as well. MSLs (medical science liaisons) are a great resource for clinical questions about therapies. There are mini-preceptorships for APPs as well, if someone is able to take time off to complete one.
Ms. Mohammadi: My advice is to think about the specific challenges patients in your specialty clinic may face, and then try to find the support to meet those challenges. I find our biggest challenge is obtaining authorization from insurance companies for medications and then making sure these medications are affordable to our patients. Our most essential resources tend to help with these two problems, and that includes our care coordinator and specialty pharmacist.
Ms. Heagy: I have several suggestions for APPs embarking on this path.
- Establish buy-in from the physicians/administrators and find a physician/administrator champion. Challenges related to overall patient access for the practice and financial considerations can emerge as arguments against an APP focusing on IBD, so having administrative support is essential.
- Make a business plan/needs assessment. Why do you need this subspecialty clinic? How is it going to help the patients, the practice and the healthcare entity you are part of?
- Make a business plan/needs assessment. Why do you need this subspecialty clinic? How is it going to help the patients, the practice and the healthcare entity you are part of?
- Start small. I started with just a half-day of IBD only, and this eventually evolved to almost full days, with general GI still scattered throughout my day. Or you could start with urgent slots (two a day) for IBD patients and work up from there.
- Communicate often with the physicians in the group. How are their patients doing? What is your plan? Who did you discuss the plan with?
- Get buy-in from all the staff and make them feel part of this clinic. It takes a lot of time to make changes in clinics, especially large clinics. Be prepared for a learning curve for reception/scheduling. Remind support staff about the goals of the subspecialty clinic.
Ms. Kearns:
- Check with other stakeholders. Be sure to ask yourself who will be involved in this endeavor and whether their objectives align with yours. Can this clinic be supported from a financial, logistic and/or organizational perspective?
- Be patient. Acknowledge that developing a specialty APP clinic takes time, so start slow and celebrate small steps.
- Assemble your team early. Delegate roles to ensure you meet expected time lines.
- Tap into available resources. Some of the most essential resources are those that I would have never considered, specifically the collaboration with the EMR team. Another essential resource would be the APP community. Reach out to your peers, ask questions about their experiences and even ask their opinions about your idea on a specialty clinic.
- Foster a strong APP–physician relationship. These programs are not possible without strong collaboration between APPs and physicians.
Ms. Enslin: Drs. DeCross and Lichtenstein, what advice do you have for APPs interested in developing clinical expertise in IBD and joining an IBD center of excellence such as yours?
Dr. Lichtenstein: There are several key “ingredients” that are important to stress to an APP who desires to establish expertise in IBD:
- Pay close attention to what the patients “say.” It is through close attention to what the patients say and also how they say it that we learn about their symptoms and what ails them. IBD care is individualized to the patient and their needs.
- Immerse yourself in IBD. Work with different IBD practitioners to learn.
- Read the literature. There are excellent resources available, from textbooks on IBD, societal guidelines, GI journals, etc.
- Attend educational programs. GHAPP is a great resource. The national societies—ASGE (American Society for Gastrointestinal Endoscopy), AGA (American Gastroenterological Association) and ACG (American College of Gastroenterology)—have great IBD-focused program content. There are not only national meetings but also regional meetings. The CCF has numerous outstanding programs as well. There are numerous CME providers who focus on IBD, including the GI Health Foundation, Vindico, Medscape and many university CME programs.
- Join the CCF. They have outstanding resources for patients and APPs alike.
- Seek advice from experienced clinicians when advice is needed. Don’t be shy, and be ready to learn. Treating IBD patients can be complicated, and it’s important to learn from others’ experience.
- Communicate with pharmaceutical companies. They have valuable resources that can assist patients. Many companies have patient educational resources and financial assistance programs that may benefit patients.
- Spend time with your patients when needed. Don’t be concerned about time by watching the clock all day. Some patients need less than the allocated time and others need more.
- Focus on disease stressors, specifically anxiety and depression. These may play a large role in patients’ well-being and response to therapy. If this aspect of their care is neglected, disease management is incomplete.
- Discuss health maintenance at each virtual or office visit. This is often neglected and is a critical part of IBD management and care.
- Communicate with other providers involved in the patient’s care. A multidisciplinary approach best serves patients and fulfills their needs.
Dr. DeCross: Learners easily can be overwhelmed by the complexity of IBD care as it stands in 2023, but you shouldn’t be intimidated by the apparent ease with which your experienced colleagues manage the myriad of therapeutic choices and navigate issues related to drug positioning, treatment contraindications and side effects. For myself, I always find it helpful to re-center my perspectives and attitudes when developing new skill sets. APPs should remember that anyone in practice more than 10 years mostly had to learn anti-TNF (tumor necrosis factor) therapy (among the advanced immunosuppressive choices), and most of our current therapy has been introduced in the last five years. So, the APP who plans to venture forth into a more IBD-centric clinical experience is on a level playing field with any starting first-year GI fellow!
There’s no substitute for diving right in under the supervision and mentorship of experienced APP colleagues and physician collaborators. It can be helpful, of course, to make use of curricular materials available through the professional societies, such as AGA’s Digestive Diseases Self-Education Program. Being at an academic center, I always am sure to onboard our IBD APPs by having them attend the medical school lectures the GI division provides to our students and by having them attend the intensive IBD therapy course that I provide for our GI fellows.
Ms. Enslin: How are APPs used in your practice to expand patient access and enhance patient care?
Dr. Lichtenstein: APPs have multiple roles in our IBD clinic:
- APPs have more flexibility in their schedules to manage acutely ill patients. They have open schedule slots to manage acutely ill patients. They can see a patient who needs an acute office visit the next day. This enables more rapid care of patients and has been demonstrated to help reduce ER visits while improving patient satisfaction.
- Telemedicine visits. APPs conduct these visits for those doing well whose insurance mandates an outpatient visit to continue to receive biologic therapy.
- Urgent care when the physician is on service. When the provider is covering the inpatient GI service (typically done in one-week blocks at our institution) there is little time to respond to patients acutely; thus, the APP takes over the urgent issues that may arise.
- Message triaging. If a practitioner is on vacation, the APP triages the messages and responds with supervision by the covering physician.
- “Doc to Docs.” When an insurance company challenges the need for use of a medication or the need for a modification of the dose of an existing medication, an APP does the phone calls. This enables a more rapid discussion since the APPs are more readily available than the physicians. Overall, we have noted that this leads to patients getting the meds they need more rapidly.
- Dose escalation request letters. The APPs work with the physicians to develop preprinted letters to request a dose escalation that is the standard of practice and is evidence based but not FDA approved.
Dr. DeCross: Our APPs are force multipliers when it comes to IBD center access. They are critical team members in an IBD center that ideally also includes IBD nurse coordinators and IBD pharmacists, as well as dietitians and social workers/psychologists. In any one IBD clinic, we’ll have a couple of IBD APPs as well as a GI fellow, and this allows me to see up to four new consults and 10 to 12 follow-up visits in a given four-hour clinic session.
However, as the majority of my time is spent in procedures, teaching or administrative duties, our IBD APPs provide a critical interface and independently manage clinical issues in a timely manner as they arise for our patients. They also handle our prior authorization “peer to peer” interactions and other practice management duties. I’ve been particularly blessed over the years to have worked most closely with two outstanding individuals, Nadine Anazi, PA, and Sarah Mohammadi, PA-C, without whom I would not have been able to deliver the level of patient care that I demand of myself, and I am grateful for these professional relationships!
Ms. Enslin: How do you facilitate APPs participating in scholarly work, including clinical trials and publications?
Dr. Lichtenstein: For those who have an interest, we are very supportive of this. We have a weekly conference that serves as a platform to present patient cases and research projects, review journal club articles, and have visiting faculty lectures on a variety of subjects. APPs have been involved in our well-regarded biannual GI IBD course as course organizers and lecturers.
In addition, we facilitate APPs being involved in clinically focused research projects and publication of review articles. I have served as a mentor to our APPs for research projects. Like other practitioners, APPs can help enroll patients in clinical trials. They also can be site investigators and review specific details about ongoing trials with patients.
Dr. DeCross: As a clinician-educator, my scholarship activity is primarily the scholarship of dissemination. The APP perspective is invaluable to clinical practice, for both providers and patients, so I’ve incorporated our IBD APPs into teaching symposiums for that reason.
This article is from the November 2023 print issue.