Kristen L. McHenry MS, RRT-ACCSDirector of Cardiopulmonary Science Program

Assistant Professor of Allied Health Sciences

East Tennessee State University

RESPIRATORY THERAPISTS AS PHYSICIAN EXTENDERS: PERCEPTIONS OF

PRACTITIONERS AND EDUCATORS

DISCLOSURE

• I have NO financial interest/arrangement or affiliations to disclose

• I will present findings from original research ONLY

PRESENTATION OBJECTIVES

1. Define physician extender/mid-level provider.

2. Recognize the outside influences that could affect respiratory therapists becoming physician extenders.

3. Compare the perceptions of practicing respiratory therapists and respiratory care educators regarding RTs serving as physician extenders.

CO-INVESTIGATORS• Shane Keene, DHSc, RRT-NPS, CPFT, RPSGT, FAARC

Associate Professor, Department Head, Respiratory Therapy Program Director

University of Cincinnati, College of Allied Health Sciences

• Randy Byington, Ed.D, MT (ASCP)

Associate Professor, Allied Health Sciences

East Tennessee State University

• Mark Washam, RRT, CPFT, RN, FNP (CNP), MSN

Assistant Professor of Respiratory Care

University of Cincinnati, College of Allied Health Sciences

• To determine the perceptions of practicing respiratory therapists (RT) and respiratory care educators regarding the role of RTs serving as physician extenders

PURPOSE OF THE STUDY

INTRODUCTION

• A physician extender is a health care provider who is NOT a physician but performs medical related procedures and other tasks typically performed by physicians (Mosby’s Medical Dictionary, 2009)

• Sometimes referred to as mid-level providers or practitioners

• Typically hold Master’s degree or higher

• Examples: Physician Assistants and Nurse Practitioners

• CoARC: Advanced Practice Respiratory Therapist (APRT)

RT’S ROLE

• The RT provides a unique and necessary set of skills, knowledge, and attributes to the healthcare environment (Myers, 2013)

• Respiratory care is an important, integral part of the current health-care system because of the prevalence and seriousness of pulmonary disease (Kacmarek, et al, 2009)

• The emergence of graduate level education has led to this exploration of RTs transitioning into the physician extender role

• Currently four graduate level (Master’s degree) CoARC accredited programs

Georgia State University (Atlanta)

Rush University Medical Center (Chicago)

St. Alexius Medical Center (Bismarck, ND)

The University of Texas Health Science (San Antonio)

RESPIRATORY CARE EDUCATION

• Diploma or certificate level

• Associate’s degree

• Baccalaureate degree

• Master’s degree

• Minimal standard for education is increasing, but the scope of practice and autonomy within the profession has not concurrently evolved

• Limited autonomy and complacency can cause stagnation and may result in skilled and experienced respiratory clinicians to leave the field in search of new challenges and opportunities to contribute elsewhere (Stoller, 2010)

LITERATURE REVIEW• Need for graduate education in respiratory care in several areas including “clinical

specialization” (Barnes, et al 2003)

• Both NPs and PAs were created to provide care to underserved patient populations and to extend the ability of the physician to care for more patients (Hooker, 2006)

• NP applicants must hold a B.S. degree and the RN credential

• PA applicants must hold a B.S. degree, but are not required to have a HCP credential or previous clinical experience (varies with each program)

• Nearly 100% of teaching hospitals in the U.S. use NPs and Pas (Hooker, 2006)

• Outcomes can improve when physician extenders are added to existing teams

AFFORDABLE CARE ACT

• Patient Protection and Affordable Care Act- 2014

• Reduce readmission rates of select diseases to avoid being penalized

• Ensuring patient satisfaction during inpatient stay

• May provide new opportunities for change in the way RC is delivered

• Emerging roles as COPD navigators and case managers

• Patient education

• Cost savings of using physician-extenders

NEXT STEP

• Given the role of the Respiratory Therapist in heart failure, pneumonia, and COPD and the current success of physician extenders in the allied health workforce, determining the feasibility of an advanced scope of practice for the profession of RC would be a logical next step

LOOKING AHEAD

• Nationwide shortage of physicians board certified in pulmonary medicine

• HRSA projects a shortage of critical care and pulmonary medicine specialists will reach 1,500 by the year 2020

• Retirement- the number of expected new entrants into the field is not expected to offset those getting ready to exit it

• Dispersion- geographically skewed leaving rural hospitals faced with inadequate staffing

• Possible solution- advance the practice of respiratory therapy with graduate education, competency assessment, and credentialing to be physician extenders for pulmonologists

STUDY METHODS

• Non-experimental

• Cross-sectional survey design

• ETSU IRB approval October 2, 2014

• Descriptive

• Survey instrument: electronic questionnaire, consisted of 17 questions

• Demographic data

• Likert scale

• Ranking

• Operational definition of physician extender provided

SURVEY

• Developed by 3 RTs and 1 professional outside discipline

• Qualitatively reviewed by each member of research team and a RT external to the research team

• Essentiality, usefulness, and necessity of survey questions

• Open from October 7, 2014- December 1, 2014

• Participation was limited to one response per IP address

PARTICIPANTS

• AARC Education Section

• TSRC Members

• U.S. RT Program Directors

• Sample of RC faculty, department directors, managers, supervisors, graduates, and practitioners from varying states

• Any participant could forward the survey to someone they knew who was a practicing therapist (snowball effect)

• Linked In open access site

DATA ANALYSIS

• SPSS Version 22

• Descriptive group comparison between educators and practicing therapists

• Independent samples t test

• 95% confidence interval (alpha < .05)

• 506 respondents

• 60.4% female

• 19.9% <5 years experience

• 35.4% >25 years experience

• 92.7% RRT

• 51.5% held a specialty credential

• 31.7% held Associate degree

• 31.7% held Bachelor’s degree

• 27.3% held Master’s degree

• 2.2% held certificate in RC

• 7.1% held a doctorate degree

RESULTS

EDUCATORS• N = 234

• 69.8% teach in Associate degree programs*

• 27.6% teach in Bachelor degree programs

• 2.6% teach in a Master’s degree program

• 24.7% <5 years experience*

• 20.3% had 6-10 years experience

• 12.1% had 11-15 years experience

• 15.4% had 16-20 years experience

• 8.4% had 21-25 years of experience

• 19.1% > 25 years experience

PERCEPTIONS

• Significant difference between the responses of practitioners and educators :

• Who should provide the appropriate clinical training to the advanced practice respiratory therapy student?

• Practitioners agreed more strongly that mid-level practitioners or physicians (pulmonologist, critical care intensivist, anesthesiologist) should provide the appropriate training

• Whether or not the respondent had considered entrance into a physician assistant program?

• Mean response of practitioners was significantly higher than that of educators

• 75.4% prefer Master’s degree

• 22.7% prefer Bachelor’s degree

• 1.9% prefer doctorate degree

• 34.8% BS degree in RC + RRT

• 34.6% identified 750 hours of clinical education as minimum for APRT

• 64.7% prefer Master’s degree

• 33.7% prefer Bachelor’s degree

• 1.7% prefer doctorate degree

• 48.2% BS degree in RC + RRT

• 30.8% identified 750 hours of clinical education as minimum for APRT

APRT EDUCATION PREFERENCES

Practitioners Educators

FACTORS IDENTIFIED

• Third party reimbursement issues were ranked as most significant possible inhibiting factor to provide APRT training

• Enhanced clinical practice was ranked as the most important factor for the development of the APRT

• Enhanced clinical practice- “the advancement of or moving forward of putting knowledge to actual use in the profession” (Dunn, 1997)

• Inpatient pulmonary and critical care medicine ranked as most preferred clinical setting where the skills of the APRT might add value to the continuum of care

DISCUSSION• Relatively equal dispersion of respondents’ education level indicates a uniformed

interest in the concept of advanced practice in the profession

• Limited opportunities for clinical advancement in RC may result in a portion of practitioners exiting the field prematurely

• This population already realizes the value of advancement and continued growth due to the high percentage of RRT credential and specialty credentials

• National majority of all RTs hold RRT credential (61.5%, n = 141,875) NBRC, 2015

• Strong agreement that RTs could adequately perform as mid-level providers after formal education

• Discipline is becoming more professional and less technical

DISCUSSION

• RC educators may feel they could also provide adequate clinical training for APRT program

• One explanation for why so many practitioners have considered a PA program is because there is currently no clinical respiratory care counterpart

• Preference for an APRT program over a PA program could be indicative of RCPs desiring to stay within their respective field of study, but with advanced training & education

DISCUSSION

• Preferred level of APRT education may be due to familiarity with the entry-level degree requirement for other allied health mid-level providers

• Primary focus of APRT adoption should be third party reimbursement

• Goal of enhanced clinical practice could result in improved patient outcomes

• Majority of RTs work in acute care setting which may be why the in-patient pulmonary/critical care option was most preferred

CONCLUSIONS

• Study suggests practitioners and educators alike are strongly supportive of advanced practice in the profession of respiratory therapy

• Regardless of educational preparation, advanced practice is perceived as important to most RTs

• Large percentage of practitioners in this study are currently contemplating or have considered attending a PA program

• Perception of RTs- if given a clearly defined pathway, they could transition into the role of physician extenders or mid-level providers

REFERENCESMosby’s Medical Dictionary, 8th edition. Physician extender. St. Louis: Mosby/Elsevier; 2009. Retrieved from http://medical-dictionary.thefreedictionary.com/physician+extender.

Myers TR. Thinking outside the box: Moving the respiratory care profession beyond the hospitals walls. Respiratory Care 2013; 58(8): 1377-1385.

Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, Oneil EH. Creating a vision for respiratory care in 2015 and beyond. Respiratory Care 2009; 54(3): 375-385.

Stoller JK. Implementing change in respiratory care. Respiratory Care 2010; 55(6): 749-757.

Barnes TA, Black CP, Douce FH, Legrand TS, et al. Development of baccalaureate and graduate degrees in respiratory care. Respiratory Care Education Annual 2003; 12: 29-39.

Kacmarek RM, Barnes TA, Durbin CG. Survey of directors of respiratory therapy departments regarding the future education and credentialing of respiratory care students and staff. Respiratory Care 2012; 57(5); 710-720.

Hooker, RS. Physician assistants and nurse practitioners: the United States experience. Medical Journal of Australia 2006; 185 (1): 4.

FULL CITATION

• Keene, S. McHenry, K.L., Byington, R.L., & Washam, M. (2015). Respiratory therapists as physician extenders: Perceptions of practitioners and educators. Respiratory Care Education Annual, 24, 19-27.

• Can be retrieved from http://www.aarc.org//app/uploads/2014/04/rcea2015.pdf

WHERE ARE WE?

• The Commission on Accreditation for Respiratory Care (CoARC) is developing standards for Advanced Practice programs (3rd draft)

• “Under the guidance of a supervising physician the APRT would be trained to assess patients, develop care plans, order and provide care based on a patient’s needs and evaluate and modify care based on each patient’s response to therapy”

• Primary roles:

• serve as physician extender in pulmonary medicine and critical care

• provide access to cost effective, quality care

• ensure delivery of best practices in respiratory care

WHAT WE STILL NEED

• A credentialing board exam in advanced practice

• Additional graduate level RC programs and faculty

• Third party payment assurance

• Scope of practice/licensure laws

• Acceptance of medical community, physicians, and mid-level providers

• The interest is there…we just need a clearly defined pathway to enter into advanced clinical practice

Thank you!

QUESTIONS OR COMMENTS?