Even a few decades ago, non-physician practitioners, also called advanced practice providers (APPs), barely existed in the health care industry. Today, APPs are found practically everywhere.  In this conversation, Michelle Schweitzer, NP, executive director of advanced practice providers at WakeMed, discusses the growing role her APP colleagues play in health care delivery, and how the rise of these unique caregivers benefits both patients and providers.

Tom Haederle

An advanced practice provider - or APP - is a health care professional with advanced training to diagnose, treat, or manage medical conditions that don't neatly fit into hospitals existing nursing or medical staff infrastructure. But their unique combination of skills and training have brought advanced practice providers into great demand nationwide.

Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. APPs have grown in number and are becoming much more integrated into hospitals clinical teams. Today, their crucial role in serving hospitalized patients across America is practically universal. In this podcast, Dr. Chris DeRienzo, AHA's chief physician executive, speaks with one health system's chief APP about the growing role her colleagues play in health care delivery and health care leadership.

Chris DeRienzo, M.D.

Welcome, everyone to another podcast here. We are at the AHA Leadership Summit in San Diego, and we are here in the Innovation Hall. And it is a true privilege that I get to sit down across the table from one of my good friends, Michelle Schweitzer. She is the chief APP at WakeMed Health and Hospitals in Raleigh, North Carolina. I have a special place in my heart for WakeMed because I got to be chief medical officer of that system before joining the AHA.

Chris DeRienzo, M.D.

And we're here in the Innovation Hub, which is a spectacular place to be because, Michelle, we'd like to talk about what is one of the most significant innovations in care delivery and in workforce over the last 15 years in health care. And that's the emergence of the APP. And specifically, we're seeing now across the country a trend towards roles like yours, chief APPs in hospitals and health systems.

Chris DeRienzo, M.D.

So just to kick us off, why don't we start a little bit around that issue? Tell me a little bit about how you came to that role and frankly, why that role exists at WakeMed.

Michelle Schweitzer

Sure. Thank you. So I will start by saying that I grew up as a nurse practitioner first before I even stepped into leadership. In fact, I went back to school to look at more research and innovative and found my way into leadership instead. Started my career managing just a few APPs, and then worked myself up to managing a whole lot of APPs.

Chris DeRienzo, M.D.

Remind me - what was your clinical role as an APP?

Michelle Schweitzer

It started out in pediatric bone marrow transplant and then it transferred into pediatric surgery.

Chris DeRienzo, M.D.

Now, you don't like sort of the easy outpatient...that's some pretty intense stuff!

Michelle Schweitzer

Yes. I was a PICU nurse before I went back to school. And of course, just like most people, I had a vision of what I was going to do when I finished. And of course, that's not at all what I was doing when I finished. Cancer was never in my book. I wanted to do actually pediatric cardiology, and I did a rotation, in bone marrow and, fell in love with the fact that I can have a patient that was sick as all get out next door and then walk into another room where patients who normally would have never survived is 15 years out and going to college.

Chris DeRienzo, M.D.

Wow. Once you've been in that kind of clinical environment, and I know we share that I'm a neonatologist and, rarely in our world as leaders do you face challenges that that even come close to that personal life or death impact. But it's tough making the transition to management. And it's not really something they teach us in our clinical background.

Chris DeRienzo, M.D.

So talk us through how you walk through that transition.

Michelle Schweitzer

In all honesty, it comes from mentorship. It started out with, you know, watching those that I looked up to and seeing how they were able to influence myself and others around me into growing into the provider that I am. And it made me want to do the same for others. And so that's really what stepped me into leadership versus education.

Chris DeRienzo, M.D.

Yep. And it made you are that leader for hundreds of APPs. How did that role come to exist?

Michelle Schweitzer

In all honesty, I was sitting in a gym and right beside me was the chief legal officer of WakeMed who said, hey, have you thought about leaving your current institution and maybe taking on a larger role, of which she described. And I was like, oh my God, that's something I can I mean, maybe in ten years I might do.

Michelle Schweitzer

However, the more I thought about it, the more I was intrigued. The ability to really make the position itself, because there wasn't really a chief APP officer. There was a smattering of leaders, but no one who was taking it and pushing it forward. So that interests me. And I interviewed, and luckily they went outside of the institution and let me come in and really gave me the span to allow me to really grow what they asked for.

Chris DeRienzo, M.D.

Well, they made a spectacular choice. But tell us more about that span, because in your health system, that role not only encompasses the employed group, but also has some accountability for many, many more APPs who rotate through an open medical staff.

Michelle Schweitzer

Yeah, the role is, it's dual, as you say. So from a system perspective, my role was really to get to know all the APS within our health system, as well as to work with credentials and med staff and really make sure that we're providing the right level of care across the system, whether they're employed or not. And then from an employment standpoint, I think when I started, it was around maybe 200 APPs and as of yesterday, which you never know, there's about 450 that are employed.

Michelle Schweitzer

So from there, it was establish a leadership structure as well as compensation structure and helping them get to the top of scope of practice.

Chris DeRienzo, M.D.

Chris DeRienzo, M.D.

and now it's frankly becoming integral to a place like Wake Med.

Michelle Schweitzer

Yeah. I think part of the challenge is that in a lot of areas, having an advanced practice provider come in to an institution that starts out with a very small groups, and then it grows from there. And so then at that point, everybody has their own thought as to what the APP should be doing or can do. They don't really fit in the nursing bucket and they don't fit into the physician bucket, but they have their own kind of bucket.

Michelle Schweitzer

And so establishing what that looks like, and it's not stepping on other toes or taking something away from other leaders is the first step that needed to happen.

Chris DeRienzo, M.D.

We know that there are listeners tuning in from all across the country, and possibly from other countries. Within your state, in North Carolina, when we use the term APP, what are the kinds of people with different clinical backgrounds who fall into the scope of your supervising?

Michelle Schweitzer

So when I think of APP inside of North Carolina, you have pretty much three different directions. So a provider who decides to go the nursing route can be a nurse practitioner, a clinical nurse specialist, a CRNA, which is with anesthesia. A provider that decides to go the medical route would be like your PA, which is a physician assistant, or in some areas called a physician associate, as well as an AA, which is anesthesia allergy assistant.

Michelle Schweitzer

And then you also have the pharmacy route, which is a clinical pharmacist practitioner. Now, depending on your state, depends on whether or not you recognize all of those levels at the same as an APP or not. But I like to say that if you're an advanced practice provider and you can do these things, then you're an APP.

Chris DeRienzo, M.D.

I love it, I love it, and we know that every state has sort of different scopes for how different kinds of providers get to be practicing in hospitals or in clinics, and through the work that you're doing here with us at AHA, I understand that we're beginning to bring some of those perspectives together in a national conversation. You're chairing that efforts.

Chris DeRienzo, M.D.

Talk to us a little bit about how your approach in that conversation with your peers in the states spanning the California coastline all the way up to the coast of Maine?

Michelle Schweitzer

Yeah. So it started with a straw man approach in the sense that we kind of got together. There was a few of us that brought all the people that we could think of all to a room and really dove into what are the main things that we need to focus on, and how do we establish what an APP is, whether you're in California or Maine or Florida?

Michelle Schweitzer

And, you know, obviously that definition doesn't need to be too extra because it needs to really be able to be utilized depending on the legislation within those, those states. And then how can we help those hospitals grow to where they can start and have an APP structure and what that would look like. And whether it's a 200-bed hospital or a system with five hospitals all combined.

Chris DeRienzo, M.D.

It's been an incredible learning process for me. I've been with AHA for a year and a half, and getting to see hospitals all across this country expose me to models of operating so different than I'd seen in in North Carolina. I was in the Midwest recently, and there was a medical staff that had four physicians on it, all full spectrum family medicine, and then more APPs than physicians.

Chris DeRienzo, M.D.

And certainly we know that that scope differs by state. But talk to me a little bit about how you've seen leadership structures differ. Again, one of the great things that we get to do through AHA's patient safety initiatives, our APP group, our chief physician network - is expose leaders who we get: it's like operations, it's hard right now.

Chris DeRienzo, M.D.

You are heads down all day every day. So it's challenging to lift your head up and get a sense of what's going on elsewhere. But what are you learning about as you get to and meet folks like Dawn, who I know is in new Jersey, and others we have within our group from Palo Alto and Kansas. And what are the things that you're hearing that you're saying, oh, this is something maybe we can take back home.

Michelle Schweitzer

Yeah, it's actually really interesting, which is I love the fact that we get together and have these sessions where we can, like, talk through certain problems and to hear from Texas versus Maine and so forth to get an idea. It's also very interesting to see where everybody is in their STEP process of where they're trying to get to.

Michelle Schweitzer

You speak of Dawn, which is actually a great new friend of mine, and we were just talking earlier about where she currently is at her institution and just getting some assistance with, with student placement and things like that. Versus at some institutions, they have an entire center for advanced practice. And how do they start? Do they start with just a committee?

Michelle Schweitzer

Did they start with just one person? And so learning from all of the different APPs from around our country to understand, like where did the grass grew and what took off and what didn't, helps us bring together from an AHA perspective of how we can put out a strategic plan so others can just take that forward without having to make it up as they go.

Chris DeRienzo, M.D.

Let's build on that for a second, because we've only got a couple of minutes left. And I'm curious if there's a chief APP, you know, who's on day one of her job or his job. And they're listening to this podcast because they saw it from AHA and they said, gosh, we want to hear what experience chief APPs are doing.

Chris DeRienzo, M.D.

And I'm on day one and I got to get started. This role has never existed before. Folks are excited, but I don't really even know where I live in this health system. If you were to give that person just three quick hits on, hey, here's the very first steps you can take that will help set you up for success.

Chris DeRienzo, M.D.

What would they be?

Michelle Schweitzer

The first step would be to know your organization. Where does your organization sit? Right now, what are they focused on and where does the APP fit into that focus? You're better off starting with what you know, obviously, and then going step forward from there. So if the organization is very focused on oh my goodness, Joint Commission is coming soon is everybody set up correctly, then probably your first step would be touching base with credentialing to make sure that your APPs aren't just privileged to do whatever, and they actually have an actual privilege that matches their scope of practice.

Michelle Schweitzer

Second is, know your stakeholders, those that are going to champion behind you, as well as those that are going to put up a fence and know how to break down those fences. Start slow. You're never going to get anywhere if you go too fast. And I guess third is make sure that you say clinical. Yes. Got to be honest, it keeps me grounded.

Michelle Schweitzer

I love my leadership role. I love mentoring all the folks that I have, but the day that I get to go into clinic and just do g-tube care, so to speak, is amazing to me and it helps me stay the person that I am, to be the leader that I need to be.

Chris DeRienzo, M.D.

I knew this was going to be a great podcast, Michelle. I so appreciate those points that frankly, they're relevant to any leader who comes from a clinical background in health care. And any time that we get to spend right at the pointy end of the stick, delivering care or being with the folks who deliver care consistently reminds us why we do the role that we do in leadership.

Chris DeRienzo, M.D.

You are a spectacular leader at WakeMed and now at the national level. Thank you so much for joining us. Thanks to everyone for listening in across the Innovation Hub here at the AHA Leadership Summit, and we will catch you next time. Take care everyone.

Michelle Schweitzer

Thanks.

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.