2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

NPS AND PAS IN SURVIVORSHIP CARE
The educational curriculum and certification for the PA
profession is based on a single national standard. Education
accreditation for all PA programs is through the Accreditation
Review Commission on Education for the Physician
Assistant (ARC-PA). The ARC-PA protects the interests of
the public and PA profession by defining the standards for
PA education and evaluating PA educational programs
within the territorial United States to ensure their compliance
with those standards. Graduation from an ARC-PA
accredited PA program is a requirement for licensure in
every state. There is a single national certification examination
through the National Commission on the Certification
of Physician Assistants (NCCPA) and is a requirement for
licensure in every state.
Practice as a PA is collaborative by definition. The profession
has defined itself and is based on a commitment to
working with physicians in collaborative teams. 24 PAs do
not practice medicine independent of their relationship with
physicians. However, autonomous practice is very common,
as physicians are not required to be present when services
are provided by PAs. Prescriptive authority is granted to
PAs in all 50 states.
Integrating NP and PA Providers into
Survivorship Programs
The professional training of both NPs and PAs lends itself
very well to the comprehensive, holistic care proposed for
survivors. This skill set allows them to provide the multiple
services needed in survivorship care including age-specific
cancer screening, general wellness, disease prevention, patient
and caregiver counseling, nutrition counseling, and
psychosocial assessment. Because many NPs and PAs have
demonstrated the ability to develop expertise in oncology
and are involved in the care of patients with cancer in active
treatment, it will be important to assess the value of the
inclusion of NPs and PAs as providers of survivorship care
and determine whether such care can be transitioned immediately
post-treatment to primary care providers as some
have suggested. 25,26,27 And although NPs and PAs are
increasingly taking on central roles in survivorship care, the
question remains whether oncologists, patients, and payors
will embrace this model nationally.
An important issue related to the transition of survivorship
care to other providers is the establishment of survivorship
eligibility criteria and surveillance guidelines. Such
guidance is a foundational step toward determining which
patients are appropriate for survivorship care and when
they can be transitioned from the oncologist to an NP or PA.
Having clearly defined eligibility criteria based on stage of
disease and risk of recurrence offers a consistent approach
and important direction for those professionals providing
survivorship care, as well as cancer survivors themselves. In
addition, guidance about the identification and management
of long-term toxicities and late effects of cancer treatments
are critical to the effective transition to other providers.
Although limited guidance currently exists for patients with
adult onset cancers, groups such as ASCO, the American
Cancer Society, and the National Comprehensive Cancer
Network have all convened national groups of experts to
address this important need.
Although NPs and PAs have the training and experience
to provide quality care to cancer survivors, it is important to
realize that there a number of factors that should be ad-
dressed before proceeding. Beyond the need for direction
from oncologists through survivorship eligibility criteria and
survivorship algorithms, there are basic regulatory considerations
and logistics to consider. Unlike physicians, who
enjoy a relatively stable scope of practice from state to state,
the legal scope of practice for NPs and PAs can have
significant variation. Some states allow broad prescriptive
authority and other states tightly regulate this authority
such that NPs and PAs cannot prescribe certain medications.
The definition of physician supervision, collaboration,
and delegation can also vary from state to state. This is
important when determining if physicians have to be physically
present or review a certain percentage of charts.
Understanding the practice act for NPs and PAs in each
state is crucial to ensure that they have the support from
physicians they need as well as a defined operational structure
in any survivorship program. 28 These logistical issues
are not insurmountable nor are they prohibitive to incorporating
NPs and PAs into survivorship programs. They are
simply issues that need to be addressed to create an effective
and efficient survivorship program. NPs and PAs have the
training, medical knowledge, and skills to provide survivorship
care; they are committed to collaborative relationships
with physicians; and they have a demonstrated role in
oncology with a commitment to lifelong learning. 29,21
Models of Survivorship Care
Internationally, as oncology physicians in hospitals, clinics,
and private practices begin to develop more efficient
approaches to the follow up of cancer survivors, they increasingly
look to the incorporation of NPs and PAs as partners.
There are well-established practice arrangements based on
the Wagner Chronic Care Model from which to choose, as
well as the multidisciplinary care model that has long been
used in the care of pediatric cancer survivors. 30 The choice of
model is most often based on the complexity of the patient
(risk for long-term and late effects) and the optimal financial
reimbursement arrangement for the medical group. The
Shared Survivorship Visit is common and has evolved into
two types of survivorship care based on the diagnosis of the
survivors being seen. First, is the multidisciplinary model,
where survivors with a variety of diagnoses are cared for,
and the survivor is seen by both the physician and NP or PA,
with each provider focusing on particular aspects of the visit.
This model is very useful for complicated patients, and in
the general medicine experience, studies have shown that
NP/PAs spend more time counseling the patient than if the
patient were seen only by the physician. The second type of
shared visit is the disease-specific model in which the
physician-NP/PA team focuses on one disease, such as
breast cancer survivors. Many groups start with this type of
care model when setting up formal survivorship services as
a way to pilot the sharing of care among providers and to
assess the financial returns. Although the billing specifics
may differ by state and payor, both types of shared visit
models offer the opportunity for joint billing in the physician’s
name. The second category of visit is the Independent
Survivorship Visit, which includes two types of care models
where the NP or PA sees the survivors independently of the
physician. The first type of independent visit is the consultative
model; this common approach is easily established as
a one-time or annual visit with an NP or PA during which
general survivorship issues are discussed and a Treatment
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