Developing and Expanding APRN and PA Teams

Ruth M. Kleinpell, PhD, APRN-BC, FAAN; April N. Kapu, DNP, ACNP-BC, FAAN; Susan Stempek, MMSc, PA-C, FCCP; Corinna Sicoutris, MSN, CRNP, FCCM; Britney S. Broyhill, DNP, ACNP-BC; Rhonda D'Agostino, MSN, ACNP-BC, FCCP, FCCM


Am Nurs Journal. 2020;15(12) 

In This Article

Atrium Health

Atrium Health, headquartered in Charlotte, North Carolina, is one of the most comprehensive not-for-profit public healthcare systems in the nation. With over 50 hospitals and 900 care locations across three states, Atrium Health has over 14 million patient encounters per year. Every day Atrium provides $5.6 million in uncompensated care and community benefit. The system employs over 1,500 APRNs and PAs.

Reporting structure

Atrium's Center for Advanced Practice (CAP) is the centralized hub for operational and academic initiatives as well as a resource for APRNs, PAs, physicians, and administrators. Formal reporting structures remain within the 10 care divisions and service lines, but CAP provides coordination across the medical group's care continuum. The senior director for advanced practice reports directly to the chief physician executive with a dotted-line report to the system CNO, oversees the CAP operational unit, and serves on the executive leadership team for the medical group. The role is responsible for overall APRN and PA strategy, compensation, regulatory compliance, communication, leadership development, and advanced practice recognition.

Four of Atrium's care divisions have directors of advanced practice who report to the senior specialty medical director with a dotted-line report to the senior director of advanced practice. The senior director for advanced practice is responsible for leading the departmental chief APRNs and PAs, as well as guiding the advanced practice strategy for the service line, hiring, and onboarding. A chief APRN or PA is elevated when a single specialty has a critical mass of six advanced practice providers working within it. The chief APRN or PA coordinates the schedule, operations, and ongoing competency evaluations of the advance practice provider team.

The APRN and PA leadership team, including directors and chiefs, meet monthly. In addition, a formal advanced practice committee reports to the medical group governance council, which is chaired by the senior director of advanced practice. The council, which includes nonleader APRNs and PAs from across the care divisions and service lines, is the decision-making body for policies, procedures, and initiatives proposed by the healthcare system.

Adding Advanced Practice Providers

The process for adding APRNs or PAs to care teams or creating new advanced practice positions at Atrium has evolved and is aligned with the physician approval process. A formal committee of executive leadership from finance, operations, and the medical group (including the senior director of advanced practice) review data (schedule capacity, access metrics, productivity, patient ratio, and scope of needed services) when considering new and replacement APRN, PA, and physician requests. A deep dive into the services that need to be added to the practice are evaluated to determine if the position requires an advanced practice provider or a physician. In some cases, the evaluation determines that the services don't require a provider at all, and another team member is a better resource allocation. A preparation committee of medical group leaders meets weekly to discuss each position request, and only those that meet the key metrics are sent to the formal committee for presentation to senior leadership.

Ambulatory practices are easy to quantify when creating new positions because of finite schedule templates, but inpatient team-based models have proven more difficult. The process for inpatient models continues to evolve, and specialty-based guidelines on patient-to-provider ratio are consulted where they exist. When a documented ratio exceeds the maximum for a quarter or more, a new position is requested or a resource scan is completed to determine if a provider can be redeployed. Other data used to justify a position include volume of patient encounters for the APRN and PA team. Internal benchmarking has been pivotal to this process.

Atrium has integrated an academic postgraduate APRN/PA strategy within medical group operations. The advanced practice academic director reports to the senior director of advanced practice and is embedded in the CAP. This role is responsible for overseeing the advanced practice fellowship, continuing medical education, and advanced practice student placements. Atrium's postgraduate fellowship program comprises over 16 specialty tracks and 50 to 60 APRN and PA fellows per year. The program launched in 2013 and has graduated 255 NPs and PAs.