Ideal Practice Model for Advanced Care Practitioners in Nephrology at an Academic Institution

The number of patients with kidney diseases in the United States continues to rise, creating a greater need for nephrology practitioners to provide ongoing management, which requires numerous long-term follow-up visits. According to the U.S. Renal Data System, in 2019, there were over 808,000 patients with kidney failure on dialysis, and the incidence rate had almost doubled from 2000 to 2019, with over 134,000 new starts (1). This increased demand for nephrology providers, coupled with the decline in physician fellowship interest (2), demonstrates an opportunity for nurse practitioners and physician assistants—collectively known as advanced practice providers (APPs)—to meet the needs of this growing patient population.

Nephrology is a multifaceted practice involving patient care in a wide variety of settings that include vast levels of knowledge and skill sets. APPs are highly trained health care providers, and when used to their maximum scope of practice, they can serve this growing patient population by increasing access to care using an independent and collaborative practice. The definition of collaborative practice may vary by state, so practice models must adjust accordingly to the needs and limitations of licensure. Most APPs will have minimal nephrology exposure in their formal education and will gain much of their specialty knowledge with on-the-job training. Nurse practitioners can further obtain the certified nephrology nurse–nurse practitioner-required 2000 hours of experience in nephrology, and physician assistants can consider pursuing a certificate of expertise in nephrology, called the Certificate of Added Qualifications. This is pursued through the physician assistant-certifying body, the National Commission on Certification of Physician Assistants. At our institution (the Medical College of Wisconsin in Milwaukee), APPs play many roles, mainly in collaborative practice in inpatient settings for consult services, outpatient dialysis weekly rounds, and out-patient transplant services.

Patients with kidney failure require complex management of anemia, bone mineral disorders, dialysis access issues, dialysis prescription changes, ongoing education, and coordination with other providers. At our institution, at outpatient hemodialysis units, APPs provide weekly out-patient dialysis unit rounds independently and consult monthly with the physician. A similar approach is used for APPs rounding on stable inpatients already on maintenance hemodialysis admitted for other reasons (Figure 1).

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Pictorial representation of ideal practice model with APPs in nephrology

Citation: Kidney News 15, 6

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There are many practice models used based on institutions' and departments' needs, as Chaney et al. (4) have explained as well. Among these models (Table 1), the “independent initiation and supervised wrap-up” model is most used in general nephrology consults and transplant services. An inpatient nephrology consultation service has some of the most complex patients needing a high acuity of care. In many academic institutions, APPs serve not only to off- load trainees but also to provide effective care in a timely manner. Using APPs allows physicians to oversee a larger patient population; spend time educating medical students, residents, and fellows; and attend to research and academic responsibilities. Nephrology APPs function in a variety of inpatient settings, which increases autonomy, allows the full use of licensure, and provides an intellectually engaging environment while using on-site continuing education and encouragement.

Table 1.

Different practice models for APPs in nephrology

Adapted from Chaney et al. (4).

In outpatient chronic kidney disease (CKD) clinics, APPs generally conduct frequent visits to provide much-needed education for different aspects of management of kidney diseases and coordination, particularly with patients who are nearing dialysis initiation. The variety of providers allows increased access to care for patients who require frequent touch points with their nephrology care team. This can increase reimbursement, such as in the outpatient dialysis setting, and more time spent with the patients will increase patient satisfaction and quality of care.

In the challenging field of kidney transplantation, APPs function in a wide range of practice areas (5). They mostly use an independent initiation and supervised wrap-up model. At our institution, APPs have exhibited a wide range of functions across all practice areas, including transplant evaluation and re-evaluation work-ups and visits; donor evaluations; and communication among family members, interdisciplinary team members, and other providers. APPs are an invaluable workforce when it comes to post-transplant care in outpatient settings to perform focused work-ups for acute rejection, suspected infections, and other complications of kidney transplant recipients.

Given the lack of a standardized training system for APPs in subspecialty practice, each institution follows its own bylaws for use of APPs. It is imperative to implement an on-boarding syllabus, mentorship, and progress model for new hires. Ongoing education of APPs on the team remains crucial to not only their practice but also for education regarding new advancements in the ever-changing field of nephrology. We use “monthly chalk talks,'' which are specifically geared toward APP education, and APPs also join divisional weekly case conferences along with a journal club as means of continued education. We are including APPs in divisional research projects, and they have proven to be invaluable members of the team.

The scope of practice and responsibilities of nephrology APPs vary among different institutions, particularly in the delivery of dialysis care. APPs' involvement in creation, development, and sustainability of health care delivery design is crucial to nephrology practice given unmet provider needs for increasing patient numbers and unmatched trained physicians in the field. Key to successful implementation of any practice model remains enhancing team care and supporting the full scope of practice for all stakeholders involved.