Building a Path Toward APP Inclusion

By Madeleine Burry
February 21, 2025 | VOLUME 3, ISSUE 1

Advanced practice providers (APPs) are a powerful, positive force in health care.

“Given the wide array of needs that a patient demonstrates, a team with a really diverse role representation is more adept at providing effective, efficient care,” said Jennifer Adamski, DNP, APRN, ACNP-BC, CCRN, FCCM, President of the American Association of Critical-Care Nurses.

When patients see physician assistants/associates (PAs), they’re typically pleased with their care. That’s true for nurse practitioners (NPs), too. It’s not only patients who benefit from APPs: In hospitals, the presence of NPs leads to greater satisfaction from staff nurses as well as efficiency.

And yet, for APPs, getting credentialed and licensed involves a tricky—and costly—process. Here’s a look at what NPs, PAs, and other APPs offer patients and practices, and the wisdom of demolishing hurdles to onboarding and additional training.

The benefits of APPs

“For APRNs [advanced practice registered nurses], our value is really that we’re grounded in both a nursing and a medical model. So, as a result, we treat illness and disease and then also focus on patients’ and families’ response to that illness or disease,” Adamski said.

Incorporating them and other APPs into health care teams means:

More patients get seen, and wait times are reduced

Improved access is one benefit to APPs providing care, said NP, Sarah Tomashefski, MSN, AGNP-C. With an APP at a practice, it’s more feasible to schedule same-day appointments for patients who are sick, and they can also tackle more routine care, allowing physicians to focus on patients with more medically complex cases or conditions, Tomashefski said.

That’s important for all patients, but particularly ones who live in rural areas, where there is a shortage of physicians.

Fostering collaboration

These days, it’s relatively uncommon for physicians—or patients—to have qualms about APPs, Tomashefski said. “It’s good for the office culture to have many different layers of providers and health care professionals who deliver care,” she said. At her institution, there’s teamwide collaboration sans competition; not only is support from peers helpful, but a huge population of patients need to be seen.

With patients who are more medically complex, having both APPs and physicians available lets them share the load of care. Plus, Tomashefski said, APPs and physicians may examine patients through different lenses based on their training. Bottom line: Interacting with more providers can lead to a fuller picture of a patient’s history.

Consistent quality in critical care

There’s a lot an acute care NP (ACNP) can accomplish in critical care, Adamski noted. After all, interns, residents, and fellows in the ICU are in training. ACNPs can both educate and mentor medical trainees, she said. They’re also in “an optimal position to provide both formal and informal education to the direct care nursing staff.”

In the ICU and other critical care environments, the presence of APPs leads to more continuity of care and improved care coordination, per a review of a decade’s worth of studies. Studies show an array of benefits to APRN teams in critical care environments: “There’s increased revenue [and] reduced cost, and what I love is the increased patient and family satisfaction,” Adamski said.

A challenging onboarding path for APPs

But, of course, all these benefits are only possible when APPs can work. As is the case for any health care provider, including physicians, joining an institution can involve Byzantine red tape and fees.

There’s merit to the licensing and credentialing process. “We need these licenses, and we need to be credentialed to make sure we’re providing safe care and maintaining a certain standard,” Tomashefski said. Provider credentialing ensures the qualifications, competence, and professional background of health care providers are thoroughly verified.

That said: “There is a need to modernize and streamline the workflow of applying for licensures and getting credentialed,” she said. Currently, the process is:

• Time-consuming: In South Carolina, where Tomashefski practices, APPs need three licenses, which must be applied for sequentially, not concurrently. Months can pass between license applications and beginning work, she said.
• Pricey: Many institutions reimburse license fees (which can top $1,000 in South Carolina, Tomashefski noted) after an APP’s start date. But that still means paying up front. “Most people, especially APPs who have recently graduated from their training programs, don’t have that much money just sitting around in a bank account,” Tomashefski said.
• Complex: Depending on the state, APPs may need a collaborating physician to sign off on all licensure paperwork before they can begin working. Some of the sign-off paperwork requires a signature in ink (an electronic signature isn’t permissible), which can be time-consuming.
• Different from state to state: If an APP moves, the process restarts. Physicians also need to apply for a license to practice in other states; but in a majority of states, they can take advantage of the Interstate Medical Licensure Compact to streamline the application process and practice in multiple states with only one application. For APPs, the scope of practice varies from state to state. A move from Iowa to the neighboring state of Illinois, for example, would mean shifting from full to reduced practice. Other states also have restricted practice. For an NP, all this may mean that a move from one state to another may mean fulfilling different requirements and figuring out a whole new round of forms and documentation.

In general, the credentialing process would be smoother if credentialing committees made a point to include APRNs and other APPs, Adamski said. Some credentialing and privileging processes can be based on medical education (which is different from APP education) or require information inconsistent with NP education, Adamski said. The NP scope of practice may be less familiar to credentialing committees, which means that NP applicants need to share additional information and paperwork, generally extending the timeline to certification.

All this adds to the time it takes to onboard new staff—and provide patients with care. “We don’t want [new graduates] to have to wait six months to start their first job. Their brains are fresh from graduating school and passing their boards. Ideally, this process [would be] much quicker,” Tomashefski said.

Why additional training benefits all

Adamski is careful to note that additional training and certification do not expand the scope of practice for APRNs and other APPs. “It simply demonstrates additional specialized knowledge,” she said.

But fellowship-type programs play an important role, Tomashefski said. “A lot of APPs go into primary care or urgent care, where you have to be well rounded in all aspects of medicine. However, if you go into a specialty field, like, for example, pulmonology, there’s a lot of things that we see every day that you may have never even heard of in NP school. And it’s not that the schooling didn’t prepare you, it’s just there’s only so much time, and they can’t teach you about every aspect of every disease state,” Tomashefski said.

Her institution has a yearlong Pulmonary APP Fellowship with specialty training in pulmonary and sleep medicine, which includes lectures, quizzes, clinical experience, conferences, and more hands-on training. The training makes APPs more prepared to take care of patients with more complicated pulmonary disease, Tomashefski said.

She believes there’s a need to expand credentialing for more invasive procedures that are quite common. Plus, in rural settings, where there’s a great shortage of health care providers, further credentialing could allow APPs to practice more autonomously, Tomashefski said.

“That’s why these specialty training programs are so important,” she said. Simply put, they expand access for the many patients in need of care and responsibilities for APPs. “We want APPs to be delivering safe, competent, and evidence-based care.”

Diverse perspectives lead to stronger patient outcomes

Why APPs as well as physicians and nurses? “Everybody has their role,” Adamski said.

Consider the critical care environment: “Our critical care intensivists are the captains of the ship, and our job [as APRNs] is to be that continuity between the bedside nurse and the physician,” Adamski said. “Everybody has their job to do to contribute to this patient’s outcome.”

A care team with an array of diverse perspectives and training leads to better care for patients. “We are a member of a bigger collaborative team,” Adamski said. “Each provider brings different knowledge, skills, and abilities, and we need to value each of those things.”