Gastroenterology and hepatology advanced practice professional outpatient clinic team

Outpatient gastroenterology services are growing at an impressive rate. Gastroenterologists are the most in-demand physician specialists, according to Merritt Hawkins and AMN Healthcare’s 2022 "Review of Physician and Advanced Practitioner Recruiting Incentives." “Growing incidences of gastrointestinal disorders, rising geriatric population, overcrowding of the Hospital Outpatient Department (HOPD), and rising preference for ambulatory services to avoid unnecessary hospitalization charges are the major factors driving the market growth.”¹ This convergence of factors, in combination with the need for greater specialization and improved access to ancillary services, warrants greater participation by advanced practice providers (APPs). Developing a care team to include APPs helps with the growing coverage demand while maintaining patient-centered, high-value care.²

Outpatient care team

In the past, a gastroenterology and hepatology (GIH) clinic team comprised a gastroenterologist and a nurse or medical assistant. Incorporation of APPs into gastroenterology practices occurred in the early 1990s.³ This model involved a gastroenterologist, an advanced practice professional, and a nurse or medical assistant. The evolving model and the future of gastroenterology include care teams comprising a gastroenterologist, a GIH APP (or 2), and a nurse or medical assistant, along with virtual support professionals such as a pharmacist, dietitian, and health coach. Subspecialized treatment teams include a specialized gastroenterologist or hepatologist, 1 or 2 APPs, pharmacist, dietitian, nurse and/or medical assistant, and a patient navigator⁴ (Table 1).

Table 1.

Gastroenterology care team model

Past	Gastroenterologist, nurse, or MA
Present	Gastroenterologist, GIH APP, or nurse, ±MA
Future	Gastroenterologist, 2 GIH APP, ±pharmacist, ±dietitian, nurse, and MA

MA, Medical assistant; GIH APP, gastroenterology and hepatology advanced practice provider.

Role of APPs in Ambulatory GI practice

Outpatient APPs in the GIH setting have a variety of advantages over the classic physician-only care model. In the general GIH practice, APPs can expand access to care, triage illness or problem-based care, increase opportunities for focused education, and provide needed short-term continuity while maintaining the quality of care.⁵ With mentorship and experience, the GIH APP can also shift focus from purely problem-based care to implementation of a preventive care program for specialized services, provide chronic care management services to decrease gaps in care that develop between office visits, and ensure appropriate preventive specialist referrals and continuity. In chronic gastroenterologic diseases, preventive care such as maintaining vaccination schedules, appropriate medication-based care (eg, laboratory testing), specialist referrals, preventive imaging, and mental health assessments can often fall by the wayside in a purely problem-based care team.

The private practice model is under constant development and improvement. Although the gastroenterologist is a regular figure in the office setting, demands for both inpatient and outpatient endoscopy limit the time gastroenterologists can physically occupy the office. GIH APPs are a constant presence in the office setting, frequently allowing for more rapid question turnaround regarding patient care. As a result, the role of the GIH APPs is more aligned with providing the conduit by which patients are provided care in the outpatient setting. GIH APPs can be offered schedule flexibility, which allows for recently discharged patients or urgent referrals to be seen in a timely fashion. This approach reflects the present-day reality of demand for GIH services outstripping the availability of the gastroenterologist. Old realities of medicine such as urgent referrals and new opportunities in medicine such as transitional care and chronic care management are precisely within the capabilities of the GIH APP. Not only does this result in improved patient care, but the opportunity for increased revenue is also appealing.

The outpatient GIH APP can provide a mix of in-person appointments, telehealth visits, patient triage escalation, chart prepping, and administrative services such as peer-to-peer and prior-authorization time. This allows for greater professional growth on the part of the GIH APP while filling gaps between the nursing staff and the gastroenterologist. The GIH APP also allows office space to be used more efficiently by preventing the dead space that typically occurs when the gastroenterologist provides outpatient endoscopic care or inpatient services.

In terms of specialized outpatient GIH APPs, this model allows subspecialized gastroenterologists to expand office-based services without the natural limitations of hiring additional subspecialized physicians. Outpatient GIH APPs specializing in inflammatory bowel disease or liver disease can even assist general gastroenterologists in providing specialized care, thus improving access for patients to specialized care for chronic diseases. As the incidence of inflammatory bowel disease increases, the exponential growth of fatty liver cases, and the “silver tsunami” outstrip all capacity for GIH care in the United States, outpatient GIH APPs and subspecialized GIH APPs will be called upon to help fill the void.^6,7

Academic GIH APPs may provide similar care for patients and will also interact with gastroenterology fellows, internal medicine residents, and medical students. Outpatient GIH APPs can provide the needed continuity of care for patients through intermittent follow-up appointments, allowing physician investigators uninterrupted time to conduct research. Although interaction with the trainees at all levels is important, experienced GIH APPs can provide consistent education and guidance to new trainees that complement and extend the training provided by the gastroenterologist (Table 2).

Table 2.

Role of the GIH APP as part of the outpatient gastroenterology care team

Increase access to care

Triage acute problem-based care

Increase focused education time

Improve the continuity of care

Provide chronic care management services

Dedicated preventive care visits

Prior authorization and peer-to-peer service

GIH APP, Gastroenterology and hepatology advanced practice provider.

Strategies to retain GIH APPs

It is hard to argue against the benefits of employee retention, specifically with GIH APPs. Private practice and academic offices need to consider nontraditional staffing models, including 4-day workweeks, varying part-time policies, and flexible schedules in combination with competitive salaries to retain valued GIH APPs. Job satisfaction often resides in having an appropriate level of autonomy with adequate access to the collaborating physician. GIH APPs need ongoing support and guidance that are based on the perception that they are a valued member of the patient’s care team. Both the physician and the APP should meet regularly to discuss patients and any relevant gastroenterology topics as they pertain to patient care. Regular communication between the APP and physician not only builds trust but ensures a strong, patient-focused affiliation, resulting in positive patient outcomes. Given the time and dollar commitment required for training the GIH APP, the investment demands a focus on retention (Table 3).

Table 3.

Retaining the well-trained GIH APP

4-Day workweek

Flexible schedules

Competitive pay

Balance autonomy with adequate support

Leadership opportunities

Practice management participation

GIH APP, Gastroenterology and hepatology advanced practice provider.

Advantages of the outpatient GIH APP

Implementation of APPs in gastroenterology practice offers several advantages to gastroenterologists, including improved patient access to care, ability to treat more patients, more time to focus on complex patients and procedures, better work–life balance, decreased burnout, increased patient and staff satisfaction, and generation of additional revenue.^7,8 When and if the payment model moves to value-based care, then limiting unnecessary emergency department visits, hospital admissions, and rescue therapy will be important markers of quality and should result in increased shared savings. Well-trained GIH APPs ensure that patient care and results-based decisions are not delayed. They can create responses to pathology, imaging, bloodwork, and prescription refills, which helps decrease the workload of the physicians and other ancillary staff. The GIH APPs can establish a better understanding of the patient’s psychosocial situation and spend more time counseling and establishing a supportive relationship for patients.¹

Challenges of adding a GIH APP to the outpatient team

A care model that transitions care from a physician to an APP has inherent risks. Poorly or inadequately trained GIH APPs could compromise patient care. This issue could be minimized through formal GIH APP training programs. Until independent specialist training programs are available for GIH APPs, a well-constructed internal training program with a combination of shadowing and book/online education followed by a period of intense oversight and then slow introduction of autonomy with easy access to continued oversight will limit this risk.

Turnover is a significant risk for any GIH APP program. GIH APPs may not be as invested in the practice as the gastroenterologist, but, as was discussed earlier, a practice needs to make a commitment to provide a superior workplace environment. We must remember, pay is only one factor provided by APPs as a reason for staying or leaving a job, and rarely is pay enough to overcome other shortcomings. Culture, benefits, and job flexibility are just a few reasons that APPs will stay with a job regardless of the absolute pay.

Will GIH APPs decrease the need for gastroenterology specialist physicians? We believe this argument for limiting APP involvement in specialist care is far-fetched. We can expect decreased reimbursement for GIH APP services when physicians have limited or no involvement, but even at breakeven reimbursement, improvement in the care continuity, office throughput, and lifestyle are well worth the effort to start an outpatient GIH APP program. As mentioned earlier, the increasing incidence of chronic GIH diseases such as Crohn’s disease, ulcerative colitis, microscopic colitis, eosinophilic esophagitis, fatty liver disease, and cirrhosis, as well as the lower ages for colon cancer screening and the “silver tsunami,” all suggest a long horizon of demand for GIH services outstripping the supply of gastroenterologists.

In conclusion, GIH APPs are an increasing presence in the outpatient gastroenterology office. From improved patient access and an enhanced patient experience to improving the lifestyle for everyone on the outpatient care team, GIH APPs are demonstrating their worth. As a specialty group, we need to focus on training, practice spectrum and limitations, and, most importantly, job satisfaction. Retention of well-trained GIH APPs is much easier than repeated recruitment. As a result, development of a collaborative culture allowing GIH APPs to participate in job design, benefit choices, practice committees, support of continuing education, the potential for leadership, and adequate pay will help create an atmosphere of stability and support that is difficult to leave. These are crucial factors in a competitive specialist APP market. We often hear administrators talk about “patient care,” and although the sentiment is understood, private practice and academic physicians need to help physician and non-physician administrators understand that if they provide excellent “provider care” then providers such as GIH APPs will provide the best “patient care.”

Disclosure

All authors disclosed no financial relationships.