Intro to PA Midterm Review PDF

Competencies 1. Knowledge for Practice – apply the knowledge you know to practice 2. Interpersonal and Communication Skills – be able to talk to people 3. Person-Centered Care – make sure the patient is center 4. Interprofessional Collaboration – work with other professionals 5. Professionalis...

Competencies 1. Knowledge for Practice – apply the knowledge you know to practice 2. Interpersonal and Communication Skills – be able to talk to people 3. Person-Centered Care – make sure the patient is center 4. Interprofessional Collaboration – work with other professionals 5. Professionalism and Ethics – be a good moral person that respects others 6. Practice-based Learning and Quality Improvement – learn and improve 7. Society and Population Health – help society as a whole The 4 Orgs of PA Life The 4 orgs is a group of four professional organizations that together define the PA profession AAPA – professional society NCCPA – certifying agent ARC-PA – accrediting PA programs PAEA – supports PA education Healthcare Delivery Systems Types of Setting Inpatient (hospital, surgery) Outpatient (office, clinic) Types of Visits Acute (flu, wheezing) Chronic (hypertension) Emergent (stroke, suicide) Preventative (Pap smear) Rehabilitative (post surgery) Palliative (End of life) Managed Care Managed Care Patients agree to only see certain providers or go to certain hospitals with whom or at which the cost of any provided healthcare services is regulated by the managing company “INSURANCE” (Est 1980s USA) Goal: Was to reduce the cost of healthcare and improve quality of care The outcome: Confusion and the creation of Accountable Care Organizations Types 1. HMO 2. IPA 3. PPO 4. POS 5. PFFS PAs in Primary Care What is Primary Care? Practice in the context of family and community The provision of accessible healthcare that meets MOST needs and builds sustained partnerships with patients 5 Key Functions Comprehensive Care (new patients) Continuous Care (chronic patients) Coordinated Care (complex patients and referrals) Accessible Care (acute visits) Patient-centered care (therapeutic relationship) PA Specialization Overview PAs have been moving out of primary care steadily over the last decade Multitude of specialties and subspecialties (PAs are in nearly EVERY medical specialty) PAs in Rural Medicine Defining Rural Care ”All population, housing, and territory not included with an urban area.” In spite of the efforts on four This can be broad: continents to meet the needs Lack healthcare resources of citizens, the rural people Lack infrastructure of the world are wanting. —Dal Poz et al., 2006 Geographically isolated Low population census 16% of world industrial population lives rurally; 10% of providers practice there (Health Resources and Services Administration) PAs in Rural Medicine PAs in Rural Medicine Distribution of PAs in Rural US Locations (per 100,000 population) Hooker, et al. Census of physician assistants: 2013 JAAPA PAs in Rural Medicine Major Issues for Rural Health PAs Professional and cultural isolation Understaffing Limited resources (pharmacy support, specialists, training, staff) Over-availability Patient familiarity: Never not working! Time demands with billing and administration Limited staff of management support PAs in Rural Medicine Incentives for Rural Practice Loan repayment (NHSC) Local community assistance Tax incentives High job demand More autonomy Typically, states with higher rural populations have more favorable legislative boards concerning PA licensure PA Economics Delegation PAs handling cases without supervision (assuming optimal conditions) Large study that came up with this number: 83% Now is the industry standard that a PA can be delegated 83% of cases (this study was in primary care) that a physician can see i.e. PAs = 83% of a primary care physician Repeat studies show something more like 90% In conclusion: PAs can be delegated a high percentage of all cases seen, can treat patients with safe and effective outcomes, cost lest, order less unnecessary tests, AND increase productivity PA Economics DEPARTMENT PATIENTS PER HOUR PATIENTS PER DAY Family practice Physician 2.39 17.4 PAs 2.61 19.0 Internal medicine Physician 3.10 22.5 PAs 2.97 21.5 Pediatrics Physician 3.14 16.5 PAs 3.07 22.3 One HMO Setting: Hooker. The roles of physician assistants and nurse practitioners in a managed care organization. AAHC 1993 PA Economics Supervision PA is legally bound to his/her supervision physician This does NOT mean that a physician must always be present! Usually regulated by individual state licensing boards as to what level is needed – In Kentucky they cant prescribe meds Typically seen as ”counter productive” in that physicians must stop what they’re doing to supervise a PA (cosign chart, sign prescription, check a lab, etc) In reality, supervision is typically a positive (more emphasis on the healthcare team in 2018) Most studies show that decreasing the physicians work load and filling in the gaps with a PA actually INCREASES productivity PA Economics Coding Overview: How a medical record is codes directly influences the level of care, the reimbursement from insurance, and the payment to the provider/hospital/office/etc Level of Care The higher the level of care: The more documentation that is required (must be coded correctly) The higher the clinical decision making (must match the amount of documentation) The higher the reimbursement (must match the decision making that matches the documentation) PA Economics Level of Care 1 through 5 (5 is the most complex) Are categorized by a five-digit series: 992(0,1)1 (paperwork) 992(0,1)2 (excludes either a history or a physical) 992(0,1)3 992(0,1)4 – heavy notes 992(0,1)5 – heavy notes 9920… New Patient (more complex) 9921… Established Patient (less complex) Example: 99213 < 99203 < 99214 < 99204 < 99215 … PA Economics Examples (very broadly) New patient, high level of care 99204 Established patient, medium level of care 99213 Medicare guidelines will reimburse about $100 on average for an established level 3 Legal Aspects of Practice Liability continued AMA Guidelines (2001) summarized: The physician is ultimately responsible for the care of all patients in the practice, group, service, or setting PAs can practice as part of the healthcare team (substitute, complement, etc) IF that role is defined by the physician and a reasonable plan is in place to monitor the PAs actions The physician must be available to the PA in some way (physical, telecommunication, or ‘other’) PAs and MDs must follow the same specialty scope of practice** Patients must be made clearly aware that a PA is rendering care Legal Aspects of Practice Malpractice Insurance Premiums PAs are split into three different classes: 1. Class A: PA assists an MD/DO in the diagnostic treatment of a patient 2. Class B: PA who is 1. Assisting in GENERAL surgery 2. Exposed to trauma/emergency procedures 10h/week 3. OB exposure including delivery room 4. Exposed to cardiac catheterization procedures Legal Aspects of Practice Certification Touched on this earlier NCCPA is the regulating body on PA certification They are the “C” in PA-C Legal Aspects of Practice NCCPA National Certification PANCE (Physician Assistant National Certification Examination) PANRE (Recertification) Qualifications for sitting for the PANCE Graduation from an ARC-PA accredited program Said program releases you eligibility to the NCCPA so you can schedule your exam PANCE Annual pass rates (for first time test takers) 93-96% Future of the PA Profession Supply and Demand Supply 110,000 active PA-C in the US (2017) 158,470 active PA-C in the US (2021) 303 PA Programs in the US Demand More roles for PAs in healthcare (specialization) Recent uptick in physician graduation rates (more PA employers) Growth of delivery systems (hospitals, health groups, and preventative medicine) Future of the PA Profession Debate over more PA autonomy ADVANTAGES DISADVANTAGES  The ability to seek employment and negotiate  If physicians are not employers, jobs may not be terms improves. as plentiful. START HERE FOR POLICY BREIF  Supervising physician can help share the  PAs may be seen as more vulnerable to plaintiff responsibility and fallout in malpractice cases. lawyers.  PAs will have a greater say in standards of care  PAs will constantly have to improve standards of and educational levels. care, seek legislative changes, and improve educational levels on their own.  PAs can negotiate salary with more  Physicians are increasingly opting for salaried independence. work.  A PA can form a business, work for the business,  Businesses are increasingly regulated with and reap the rewards of one’s own labor. compliance consuming large amounts of time and resources.  Independent reimbursement from insurance  Many third-party payers may resist another companies will improve return for work. reimbursement seeking group. Standard of Care: Definition: In legal terms, the level at which the average, prudent provider in a given community would practice Legality: If a provider fails to provide ”standard of care,” that provider is subject to errors/omission malpractice. We will learn these ”standards” as we move into core curriculum Medical Errors and Adverse Events - Hippocrates (2000 BCE): “First do no harm.” - Define - Medical Errors: Preventable adverse events either committed by COMMISSION (active harm: Malfeasance) or OMISSION (passive harm: Negligence). - Adverse Events: Nonpreventable cause of harm resulting from treatment or natural disease course  Types of Medical Errors Medication Errors Dosing, scheduling, contraindications, toxicity Surgical Errors Wrong-site surgery, technical error, anesthesia complications Diagnostic Errors Delayed treatment, wrong treatment, worsening conditions Handoff Errors When patients change providers or services (shift changes) Iatrogenic Infections Hospital or healthcare associated infections  Risk Management Division of healthcare focused on designing practices and systems that help reduce errors and adverse events to improve patient care Discuss this in terms of two main systems: Double Check Systems - A forced dual signoff is a feature of an electronic medical record (EMR) that locks a screen until a second nurse signs off on a double check Forced Functions- if you want to prescribe a med that someone is allergic to you have to physically write something MDM Developing the MDM Begins with patient evaluation Medical History Physical Exam Laboratory or diagnostic data Formulating a diagnosis Proposing a treatment Patient’s Goals (cost effective, safe, patient compliance, true benefit) - MDM Two types of Medical Decision 1. Diagnostic What needs to be done to make the diagnosis? 2. Therapeutic What needs to be done to maximize the treatment? Either way, both must involve the “best evidence available” and both must involve the patient’s input/preferences Shared decision-making MDM Making the Decisions (Dual process theory) Intuition (gut feeling) Rapid, effortless judgement (cannot be traced) don’t go down rabbit hole Uses pattern recognition and heuristics (“rules of thumb”) Analysis (charting) Slow, deliberate thinking Requires research, methodology, and can be be traced Note: BOTH CAN BE INFLUENCED BY BIASES MDM Biases Bias Description Availability Think about easy-to-remember or most recent diagnoses regardless of prevalence Base Rate Neglect Pursuing “zebras” – rare diagnoses Representativeness Ignoring atypical features that are inconsistent with the favored diagnosis Confirmation Bias Seeking data to confirm vs refute the initial hypothesis Premature Closure Stopping the diagnostic process too soon MDM Other Influences on decision making Practice Style The clinical behaviors of the individual provider Personal experience (“expertise”); Specialization; how one interprets the medical evidence Practice Setting Resources available to the practice, provider, or community Economic Incentives Following the money can lead to both GOOD and BAD influences on patient care Differential Diagnosis - DDx Introduction What is a Differential Diagnosis? (Abbreviated “DDx”) A prioritized LIST of all possibilities based on the unique clinical findings of a patient A process to evaluate information or results to narrow decisions to a working, accurate diagnosis In the beginning... You will have huge differentials and try to follow a process to eventually get a diagnosis Over time, you will make better use of Expertise, Pattern Recognition, and Risk to make faster, more accurate decisions Differential Diagnosis Formulating the DDx 1. Start with basic patient information Symptoms (hx) Signs (phys exam) 2. Rank Order Most Likely → Most Common → Most Dangerous → Least Likely 3. Investigate Treatment and response? Order lab or image? 4. Did it work? Is what you thought still what you think?