Christina Gardner, DHSc, MBA, PA-C; Alexandra Nassif, PA-C; Connie Brooks, MSN-FNP; and Kim Roe, MBA, RRT
Urgent message: Postgraduate fellowship programs are essential to the development of highly trained providers who can support the ongoing growth of the urgent care marketplace in the midst of a national physician shortage. However, historically there have been view available to nurse practitioners and physician assistants.
A 2017 report of the Association of American Medical Colleges (AAMC), predicted a shortage of 40,800 to 104,900 physicians by 2030.1 One of the best methods to address this physician shortage is to utilize advanced clinical practitioners (ACPs) in all fields of medicine, but perhaps no place more so than in urgent care. Since 2005, there has been an increase in the acceptance and utilization of team-based care, which utilizes ACPs, in most healthcare systems.2 Now that ACPs are working within a clinical team, the next logical step is to allow for team and interprofessional training to occur to further team-based care, increase the autonomy of the ACPs in the appropriate clinical settings, and to provide increased access to care for patients.
Carilion Clinic, a fully integrated health system operating seven hospitals and eight urgent cares in southwestern Virginia, has developed a novel interprofessional postgraduate fellowship program that allows for ACPs to train together with a special focus on urgent care medicine. This article will discuss postgraduate training in urgent care medicine as it relates to practice management challenge in urgent care centers, and the solution for these issues in the form of an urgent care fellowship model for ACPs.
The Case for Urgent Care Medicine-Trained ACPs
Urgent care is essential to lowering the cost of healthcare, increasing access to care, and decreasing emergency department overutilization. Seventy-three percent of Americans who report having no access to primary care on nights, weekends, and holidays report that urgent cares provide access to care at a substantially lower cost than EDs.3 Evaluation and treatment for common illnesses such as urinary tract infections, allergies, or upper respiratory infections cost 3.5 to 6 times more at an ED than at an urgent care center.4 Urgent care provides medical services to a high volume of patients and requires providers to quickly assess situations and efficiently perform procedures, including suturing, splinting, foreign body removal, incision and drainage, and pelvic exams. In 2014, on average, urgent care providers cared for four patients an hour with an average of 50 patients per day. Further, 91% of urgent care centers expected growth in the next fiscal year.5 Similarly, ACPs are being utilized more in urgent care every day, and 50% of urgent cares have an ACP as part of their staff.6
The need for postgraduate fellowship-trained ACPs was initially determined from the trajectory of healthcare in the United States. Americans make more than 350 million visits to healthcare providers per year for acute care, but fewer than half involve the patient’s primary care physician.7 Urgent care medicine fills a critical need for access to care due to the shortage of family medicine practices, few available primary care appointments, and the overcrowding of EDs. In response to the increased utilization of urgent care, more ACPs are being hired in these clinics, sometimes working as a solo provider. However, newly graduated ACPs are often not prepared for the high volume of patients that they are expected to see. Consequently, key goals of postgraduate fellowships are to prepare all ACPs for the varying levels of patient acuity they will see in urgent care, refine necessary procedural skills, increase their breadth of knowledge through didactic training, and increase their patient flow in preparation for managing a busy urgent care clinic.
Practice Management Solutions
ACPs will continue to be called upon in greater numbers to meet urgent care practice management challenges in provider staffing, patient flow, provider efficiency and quality of care, and customer satisfaction. Incorporating ACPs can ease the burden on the remaining physicians in practice, improve provider staffing ratios, and generally ensure smoother operation during patient volume surges.8 Urgent care-specific postgraduate fellowship programs can help ensure they’re prepared to do so.
Typically, newly hired ACPs are only provided a 30-day orientation program that is not designed to increase their medical knowledge, but rather to orient them to the electronic medical record, and to the clinic. As such, it is vital to patient care and safety to have fellowship training programs aimed at increasing their competency and efficacy. Goudreau, et al reported on the induction of a yearlong nurse practitioner residency at a Veterans Health Administration facility, noting that the directors of this program were aware of the many challenges faced by the novice NP, including the difficulty of managing the large volume of patients with complex medical conditions that the VHA serves.9 This residency, which is akin to a fellowship program, served to provide an easy transition into the new role, improve collegiality between peers, and, most importantly, increase the competence of the NP resident.
Additionally, fellowships aid in retaining fellowship-trained ACPs and decrease the turnover rate of these providers. Research from Kells, et al supports the use of fellowships to increase recruitment and retention of ACPs.10 Kells, et al also report on the need for further specialty training of ACPs going into specific specialties, such as urgent care medicine, as they may not have been provided such education in their respective graduate programs.10
Historically, there has been no generally accepted training program for ACPs in urgent care medicine (except for on-the-job training). Urgent care medicine is also not specifically taught in PA or NP programs. With the breadth of medical issues presenting to urgent care, the limited amount of time available for training, and the growth in urgent care facilities run by ACPs, fellowship training is a logical next step in the evolution of ACP training. It’s been only in the past 12 years that fellowship programs for ACPs became available across the country. Currently, there are 62 fellowship programs for PAs and 102 for NPs in the United States.11,12 However, very few specialize in urgent care medicine. Carilion Clinic’s Advanced ACP Fellowship in Urgent Care and Rural Health is one, having been designed to embrace interprofessional learning for both NPs and PAs.
This fellowship is unique, to our knowledge, in its incorporation of rural medicine, urgent care medicine, weekly didactic components, and the variety of clinical experiences provided to the ACP fellows. Additionally, as with any fellowship, the interprofessional relationships that are built through the various rotations are invaluable. The ACP fellows work together, but they also benefit from didactic training with family medicine resident physicians.
The Carilion Clinic Advanced ACP Fellowship in Urgent Care and Rural Health begins with a 4-week intensive didactic training course, called Boot Camp. This time is spent reviewing the major topics the fellows will encounter throughout the fellowship year and are specific to urgent care medicine. Boot Camp is intended to enhance a wide variety of skills through lifesaving courses, EMR training, and urgent care orientation shifts, as the fellows learn how to transition didactics to clinical practice efficiently. The fellowship includes clinical rotations in Urgent Care, Primary Care, and off-service rotations such as Emergency Medicine, Pediatrics, Obstetrics and Gynecology, Occupational Medicine, Ophthalmology, Orthopedics, Wound Care, Home Health, Psychiatry, and ENT. Close collaboration with urgent care physicians and specialist providers serves to increase exposure to a wide array of medical issues, increasing the confidence of the ACP in diagnostics and creating treatment plans. The clinical rotations also further prepare the ACP to practice without ordering labs or imaging studies that may retrospectively be deemed unnecessary.
Once in the urgent care setting, shadowing shifts allow the fellows to become comfortable with the EMR, staff members, and different practice locations. Over the first 6 months of the fellowship year, the fellows serve as “additional” providers during their clinical shifts in the urgent care center, thus enhancing, instead of inhibiting, patient flow. Fellows work closely under the supervision of attending physicians during their clinical shifts.
Numerous evaluation techniques have been implemented to ensure the success of the fellowship and provide 360-degree evaluation. Three series exams are given to the fellows throughout the year to assess the knowledge base and to track their progress. Preceptors complete evaluations on the fellows as soon as the rotation has ended. This allows for a firsthand account of the fellows’ skill level and also identifies areas for potential growth.
Fellows complete evaluations on each preceptor and clinical rotation. Likewise, the director of the fellowship routinely completes evaluations of each fellow with information gathered from exams, weekly quizzes, preceptor reports, and personal interactions. The fellowship director stays in close contact with the ACP fellows to ensure continued coaching and support, in addition to welcoming recommendations from the fellows regarding didactic content and areas where the fellowship could further enhance learning.
Furthermore, didactic, academia, and research components are incorporated into the curriculum. Didactic lectures specific to urgent care medicine are provided 1 day per week. Additionally, weekly conferences are attended by the ACP fellows with the family medicine residents. Advanced skills are taught during didactics through the utilization of an advanced simulation lab. Advanced procedural skills (eg, suturing, obstetric delivery, advanced airway management, ultrasound-guided IV placement, chest tube placement, and lumbar punctures) are practiced throughout the fellowship year via simulation.
The ACP fellows also participate in academic pursuits throughout the fellowship year, including providing lectures to other PA and NP programs on various topics, as well as presenting lectures at state conferences.
The ACP fellows conduct research throughout the fellowship year, as well. Carilion Clinic’s ACP fellowship program has collaborated with Jefferson College of Health Sciences (JCHS) to provide an optional healthcare administration component to their education. JCHS has provided three courses during the fellowship year, which allows the fellows to work toward the Graduate Certificate in Healthcare Administration.
Upon completion of their training, these ACP fellows should be highly skilled practitioners able to care for patients effectively and efficiently in an urgent care setting, while also being well-rounded practitioners with experience in research, academia, and healthcare management.
The Carilion Clinic Advanced ACP Fellowship in Urgent Care and Rural Health has retained 100% of its ACP fellows upon graduation in its inaugural year. Thus, the ACP fellowship has been able to directly address practice management challenges regarding recruitment, staffing, and retention of highly qualified providers.
The success of any practice lies in outcomes, patient safety, provider recruitment and retention, and patient satisfaction. Urgent care clinics are no exception. Typically, however, their fast-paced environment is not conducive to a “breaking in” period for newly employed ACPs—at least to the degree necessary to be efficient and autonomous in the typical 30-day orientation timeline. At the same time, with the increasing utilization of ACPs in urgent care clinics, the need to develop postgraduate fellowship training programs has risen. Carilion Clinic’s Advanced ACP Fellowship in Urgent Care and Rural Health has demonstrated that an urgent care-specific solution to the most common urgent care practice management challenges is not only feasible, but advisable. To solve the practice management challenges inherent in staffing urgent care clinics, retain qualified providers, improve patient flow, and increase customer satisfaction, the adoption of an ACP fellowship training programs is suggested.
- Gudbranson E, Glickman A, Emanuel EJ. Reassessing the data on whether a physician shortage exists. JAMA. 2017;317(19:1945-1946.
- Dehn RW, Everett CM, Hooker RS. Research on the PA Profession: the medical model shifts. 2017;30(5):33-42.
- org. Emergency rooms vs urgent care centers. Available at: https://www.debt.org/medical/emergency-room-urgent-care-costs/. Accessed June 28, 2017.
- Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses: Comparing retail clinics with other medical settings. Ann inter Med. 2009;151(5):321-328.
- Benchmarking survey headlines summary. Urgent Care Association of America. Available at: http://c.ymcdn.com/sites/www.ucaoa.org/resource/resmgr/Infographics/2015_BM_Survey_Headlines_Sum.pdf Accessed December 15, 2017.
- Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: Findings from a national survey. BMC Health Services Research. 2009;9:79.
- Pitts SR, Carrier ER, Rich EC, Kellermann, AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Affairs. 2010;29(9):1620-1629.
- Dill MJ, Pankow S, Erikson C, Shipman S. Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Affairs. 2013;32(6),1135-1142. http://content.healthaffairs.org/content/32/6/1135.full.pdf+html. Accessed June 5, 2017.
- Goudreau KA, Ortman MI, Moore JD, et al. A nurse practitioner residency pilot program: a journey of learning. J Nurs Ad. 2011;41(9):382-387.
- Kells M, Melchiono M, Burke P. Advanced practice nurse fellowships: Creating awareness, creating opportunities. J Pediatr Health Care. 2015;29(3):297-301.
- The Association of Postgraduate PA Programs. Carilion Clinic advanced ACP Fellowship in urgent care and rural health. APPAP. Available at: http://appap.org//?s=urgent+care. Accessed June 01, 2017.
- Nurse Practitioner Schools. Primary care and family health. Available at: http://www.nursepractitionerschools.com/blog/np-fellowship-residency-programs. Accessed January 30, 2018.