By Camille Petraitis, DNP, FNP-BC, and Christine Schlemmer, PA-C
Advanced practice providers (APPs), comprised of both nurse practitioners (NPs) and physician assistants (PAs), are highly trained, qualified medical professionals who play a vital role providing clinical care to patients with cancer.1 The role of the hematology and oncology (HemOnc) APP focuses on direct patient care but may vary depending on the practice setting.
Cancer care is complex and requires extensive training and onboarding for APPs entering the subspecialty. All HemOnc advanced practice involves increased collaboration with physicians given the complexity and acuity of the vulnerable patient population compared with other specialties or primary care practices.1,2 There are three core APP roles within HemOnc: outpatient, infusion, and inpatient. Outpatient APP roles focus more on survivorship, complex triage, and the chronic medical care of the patient. Infusion-based APP roles require acute oversight of infusion reactions while maintaining chronic medical care of patients. These roles often complete high-level symptom management visits for patients actively receiving systemic therapies in the outpatient setting. Lastly, dedicated inpatient APP roles require acute medical care and intervention of the patient through a multidisciplinary approach in the hospital setting.
This article aims to discuss how the roles and responsibilities of APPs in care teams vary based on the practice setting with an emphasis on inpatient roles and focused on a dedicated inpatient medical oncology role at a nonprofit hospital in Charlotte, NC.
Inpatient Cancer Care APP Roles and Responsibilities
While this may vary among institutions, the Inpatient Medical Oncology Solid Tumor Consult Service Team at an academic center nonprofit hospital includes multiple APPs, attending physician, pharmacy, nurse liaison, and a rotating number of learners, i.e., medical residents, MD fellows, APP fellows, and medical and APP students. The APP role is essential to the HemOnc practice in both the outpatient and inpatient settings. The inpatient APP delivers care in a high acuity and constantly evolving setting, sometimes necessitating multiple visits throughout the day depending on results, clinical status, or other subspecialty questions. The APP is responsible for chart review, individual daily rounds, work-up, ordering diagnostic imaging and interpretation, assessment, and recommendations in addition to order entry. The greatest amount of time, however, is devoted to care coordination for individual patients outside of the patient room, with family members, hospitalists, histopathologists, radiologists, surgeons, cancer nurse specialists, physical therapists, clinical nutritionists, and radiation oncologists.3 In addition, multidisciplinary rounds to include social work and case management in the HemOnc unit are held daily, which are the gold standard means of addressing the complex needs of patients with cancer.4 These daily rounds have been proven to show higher rates of ICU admission and lower mortality rates compared with daily patient care without daily rounds.4
The outpatient APP relationship is built over a prolonged time period, whereas the inpatient APP-patient relationship is formed relatively quickly. The nature of escalated care creates the need for discussions of serious illness, promoting realistic care which is consistent with the patient’s wishes.5 This goal-concordant care effectively bonds the APP with the patient and family unit as life goals are discussed and care plans are implemented. Pivotal discussions held in the inpatient setting must be relayed with patient’s primary outpatient oncologist and team for best practice and effective transition of care across settings. Due to inpatient care coverage models, the relationship is much shorter and piecemeal. The relationship ends abruptly as discharge occurs, as does the infusion APP-patient relationship after therapy completion.
The inpatient oncology APP improves patient outcomes and results in positive professional experiences for oncology care providers. Inpatient APPs who have undergone institutional privileging and credentialing for managing chemotherapy orders provide a valuable service when inpatients require active cancer-directed treatment.6 The integration of APPs in inpatient cancer care promotes shared responsibility among providers and ensures that qualified providers manage chemotherapy in this setting. Beyond productivity measured through billable visits and work relative value units (WRVU), inpatient APPs contribute to other aspects of care, including administration, teaching, and quality improvement.7 APPs have responded to the growing complexity of oncology patient care with advocation of the inpatient nurse liaison role. Together, the inpatient APP and inpatient nurse liaison have created a standardized discharge process which has helped to decrease time to HemOnc follow-up appointments, improve communication between inpatient and outpatient teams, and decrease process variation.
Inpatient APPs are at the forefront of collaborative communication, bringing together the required subspecialists for each patient case. Effective interprofessional communication not only enhances patient care but also provides optimal shared decision-making among interprofessional care teams.2 As the APP assesses the next patient's needs, they seek subspecialty groups to come together to learn with and from each other, working towards a common goal of best patient care using skills and expertise of each profession.
In summary, the role of the HemOnc APP may vary depending on state rules and regulations, institutional bylaws, and culture of the practice. It is pivotal to integrate APPs into workforce strategies to expand the capacity of HemOnc physicians and enhance access to quality cancer care. Understanding the scope and intended function of the APP role will help to drive best practices for patients with cancer.
- Bruinooge SS, Pickard TA, Vogel W, et al. Understanding the Role of Advanced Practice Providers in Oncology in the United States. J Oncol Pract. 2018;14:e518-e532. doi: 10.1200/JOP.18.00181.
- D'Alimonte L, McLaney E, Di Prospero L. Best practices on team communication: interprofessional practice in oncology. Curr Opin Support Palliat Care. 2019;13:69-74. doi: 10.1097/SPC.0000000000000412.
- Soukup T, Lamb BW, Morbi A, et al. A multicentre cross-sectional observational study of cancer multidisciplinary teams: Analysis of team decision making. Cancer Med. 2020;9:7083-99. doi: 10.1002/cam4.3366.
- García-de-Lorenzo A, Jiménez V, Feliu J, et al. Multidisciplinary rounds in oncology and hematology: Are they superior to rapid response teams? Med Intensiva (Engl Ed). 2021;45:127-8. English, Spanish. doi: 10.1016/j.medin.2020.01.011.
- Clarke J, Momeyer MA, Rosselet R, et al. Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project. J Adv Pract Oncol. 2023;14:37-48. doi: 10.6004/jadpro.2023.14.1.3.
- A Carrasquillo M, A Vest T, S Bates J, et al. A chemotherapy privileging process for advanced practice providers at an academic medical center. J Oncol Pharm Pract. 2020;26:116-23. doi: 10.1177/1078155219846959.
- Kurian T, Stranges E, Czerlanis C. Standardization of the Discharge Process for Inpatient Hematology and Oncology Using Plan-Do-Study-Act Methodology Improves Follow-Up and Patient Hand-Off. Fed Pract. 2021;38(Suppl 2):S50-S56. doi: 10.12788/fp.0126.