Promoting Independent Advanced Practice Nephrology Care

Need for Increased Nephrology Workforce

There are approximately 37 million adults in the United States with impaired kidney function and/or proteinuria and nearly 800,000 patients with prevalent kidney failure in 2021.¹ Our profession has been challenged with an ambitious yet vital goal to increase home dialysis modalities and transplantation.² The number of patients, and the time they require for excellent care, is increasing, whereas the number of nephrologists and nephrology fellowship applicants is decreasing.³ At the same moment, the United States is experiencing an increase in advanced practitioners joining the health care workforce: nurse practitioners and physician assistants, licensed independent providers with nursing or other health care backgrounds who have achieved advanced education and training. Studies project this group will number over 400,000 by 2023 and will continue to grow.⁴

Nurse practitioners and physician assistants have practiced in nephrology for many years,⁵ and collaborative practice has demonstrated increased access to care, improved patient satisfaction, and improved outcomes.⁶ To meet the needs of our patients, avoid redundancy, improve efficiency, and further advance the field of nephrology, it is critical that we increase utilization of independent advanced practitioners. Clarity regarding the education and training of the advanced practitioner may be needed in order to promote independent practice. Additionally, the traditional practice that advanced practitioner work must be supervised by physicians, or that advanced practitioners may only carry out physician-derived plans,⁷ may lead to underutilization of the skills of advanced practitioners in nephrology practice settings.

By promoting advanced practice in nephrology and using a value-based practice model that best suits the patient, care setting, practitioner, and physician, we can work toward achieving these goals, as well as achieving improved access to care, decreased wait times, and decreased hospital admissions. It will also allow for improved efficiency on all providers' parts and will provide the physician with more opportunities to teach trainees, conduct research, and care for complex or specialized nephrology patients. In addition, sharing the workload may reduce provider burnout. By working together, physicians and advanced practitioners can maintain the highest standards of care without sacrificing financial prudence.

Training, Mentorship, and Certification of Nephrology Advanced Practitioners

As advanced practice education is generalized, once the provider begins in nephrology, individual training and mentorship is key. New-to-nephrology advanced practitioners may be paired with physician mentors or experienced, nephrology-certified advanced practitioners through their dialysis or CKD clinic and regularly perform dialysis rounds together, review charts, and discuss clinic visits and patient plans, an apprentice-like training similar to a fellowship or internship approach. A nephrology-specific advanced practice fellowship would allow the advanced practitioner to expand their knowledge base both broadly and deeply and could include formal didactic education and training across all nephrology care settings. Including advanced practitioners as contemporaries in the practice setting and providing access to education and professional development will lead to higher engagement, higher retention, and improved satisfaction, allowing them to become independent in their role as nephrology-specific providers.⁸

Furthermore, their training and background in nursing, bedside care, and other arenas both within and outside of health care provide advanced practitioners with valuable experience and ability to provide holistic care for patients as persons, as well as a deep understanding of the logistics of the health care setting and the practicalities of caring for patients across these settings, leading to streamlined and effective services.

Advanced practitioners also have the opportunity to obtain optional specialty certification in nephrology. These certifications require significant preparation, years of practice in nephrology, and many hours of specialized education^9,10 and demonstrate expertise in nephrology to those within and outside the profession. Institutions and employers should ensure advanced practitioners have access to the training, funds, and support to achieve and maintain specialized certification, and certification should be sought for all advanced practitioners who are eligible.

Once the advanced practitioner has been trained in the field, gained experience, and demonstrated expertise in nephrology, the practitioner should be considered able to practice independently within their scope of practice and credentialing and to manage patients in various practice settings, without unnecessary and redundant oversight and with appropriate visibility and accountability, leading to increased access for patients and shared workload for providers.

Moving Forward: Achieving Value-Based Care with Nephrology Advanced Practice Care Models

Looking to the future of nephrology, value-based care, with cost-effective, intentional, and purposeful care for patients to provide outcomes-based reimbursement, becomes necessary. Advanced practitioners, with diverse perspectives and background as well as extensive, practical experience and training in collaborative team-based care models and care coordination, are well placed to lead this change. Productivity is increased and work effort improved by avoiding the redundancy that occurs through shared physician–advanced practitioner visits.⁸

In the hospital setting, seasoned practitioners may function independently to manage acute or CKD consults. New practitioners would benefit from working alongside a mentor, rounding on patients and developing plans collaboratively until they are ready to function independently. Advanced practitioners are also able to provide valuable continuity of care between practice settings, identifying and assisting with “big picture” issues, which may ultimately prevent rehospitalization, improve quality of life, and improve patient and family satisfaction. By avoiding duplicate work, the physician is able to focus on other tasks.

In the dialysis units, advanced practitioners can act as primary dialysis providers, developing focused skills in this subset of nephrology patients, centering on quality metrics to improve care delivery. Managing both the medical and sociocultural complexities of hemodialysis is within the independent provider's scope of practice, as well as completing the monthly comprehensive visit for patients. As primary dialysis providers, advanced practitioners share the workload with physician colleagues, together offering focused care to more patients.

In the United States, the Advancing American Kidney Health Initiative (AAKHI) 2019 has challenged us to shift to most of the patients initiating dialysis on a home modality and increasing transplantation. Using an independent practice model in the ambulatory setting, advanced practitioners are well suited to focus on the transition to dialysis, directly addressing the AAKHI. The practitioner provides ongoing education and streamlines access to fistula or peritoneal dialysis catheter placement, along with a multidisciplinary evaluation, ensuring a smooth start to kidney failure care. Doing so will avoid “crash” hospital starts, improve patient satisfaction and quality of life, increase home dialysis modalities, and improve the value of our care. Furthermore, allowing advanced practitioners to focus on this area will free physicians to care for complex and specialized nephrology patients.

Various practice models are demonstrated in Figure 1.

Figure 1.

Nephrology advanced practice. NPI, National Provider Identifier.

Collaborative Practice to Advance Kidney Health

Considering the increase in patient numbers, reduced physician nephrologist workforce, and the need for proficiency and effectiveness in our practice, along with our overall professional goals of increasing home modality starts and the value of strong continuity of care between various nephrology practice settings in a high-risk population, we can conclude that promoting independent advanced nephrology practice is crucial at this moment. Our goals cannot be achieved without a team approach, without broadening our view, and without using a more contemporary approach of independent nephrology advanced practice. It is time to bury old practice patterns and embrace a bold new opportunity to advance kidney care. Our advanced practitioners are present and prepared for this new challenge, and our patients deserve a new care model.

Disclosures

The author has nothing to disclose.

Funding

None.

Author Contributions

Writing – original draft: Leah J. Wayner.