HealthSeptember 12, 2022

Evolving decision support for PAs, NPs, and the rise of urgent care

During the pandemic, crowded hospitals and staffing shortages helped accelerate a trend already changing healthcare over time: The increase in reliance on ambulatory care and urgent care centers.

These care settings are most commonly staffed by advanced practice clinicians like physician assistants (PA) or nurse practitioners (NP). These licensed and rigorously trained professionals have master’s degrees (and some PhDs) and are certified to make diagnoses, conduct testing, and prescribe treatments. In busy urgent care settings, they often rely on Clinical Decision Support (CDS) systems to help them quickly find answers to diagnostic questions without keeping patients waiting.

“When I worked in urgent care, I’d work a 12-hour shift, and I was the only provider there all day. There were days when I literally had 30 patients waiting at one time,” says one licensed physician assistant and clinical specialist at Wolters Kluwer. “So, easy-to-read, clear information would be incredibly helpful for me when I quickly needed to confirm and verify evidence-based recommendations.”

What current trends impact growth in urgent care and ambulatory practices?

The Urgent Care Association reported in 2019 that the total number of centers in the U.S. had topped 9,000, representing a 9.6% increase over the previous year and a steady continuation of growth since 2013. The association also reported that 92% of provider visits at those centers took 30 minutes or less, which it touted as an efficient patient experience. According to research, during the pandemic when hospitals, primary care offices, and ERs were too clogged to receive routine patients, urgent care centers saw a 58% increase in volume of visits.

The increase in reliance on urgent care and outpatient clinics doesn’t surprise the Wolters Kluwer physician’s assistant, who has been licensed for 15 years, training for the role after first working in healthcare as a volunteer, a nursing assistant, a phlebotomist, and performing autopsies. After becoming a PA, she practiced in a variety of care settings, from ambulatory internal medicine to hospital-based cardiovascular care, to home health, hospice, and urgent care centers.

“Primary Care Physicians are getting burned out,” she explains. “The healthcare systems are overwhelmed, and patients can’t even get in to see their providers for care they may need in a timely manner. So, they end up seeking care at urgent cares.”

The alternative, she notes, is that overwhelming responsibility falls on primary care providers in ambulatory practices, because patients are unable to book timely appointments with specialists. The result is that clinicians like her are experiencing “the level of care that is happening in the outpatient setting is more [volume] and at a higher level. This is creating increased volume, complexities, and demand at urgent cares.”

Do PAs and NPs approach care differently?

While clinicians may be struggling under a more taxing workload, business at urgent care centers is booming. “Urgent cares are learning that they can make more money” from this expanded care model, the PA observes. “They don’t want to just see a cut finger and do stitches. They want you now to come back and make us your primary doctor. We can do your annual labs. We can do your health physicals. We can get your vaccines. We can care for your diabetes. They wanted us to bring the patient back as often as possible.”

Success is evident in industry data: A first-year U.S. urgent care clinic was averaging $1.1 million in revenues in 2019. By 2021, those first-year revenue estimates had swelled to $2.3 million.

However, this can lead to increased turnover for the PAs and NPs who provide the care at express clinics and urgent care centers, where often there is only one primary medical doctor overseeing a team of advanced practice support staff. While PAs and NPs are fully trained medical professionals, the PA explains, these clinicians do take a slightly different approach to care in clinic and outpatient settings “because your access to information is drastically different. If a patient came in with a suspected clot in the leg, in the urgent care setting, we don’t have ultrasounds at the bedside. So, we’d have to say, ‘You need to go to the hospital.’”

It forces advanced care practitioners to approach patients differently than they might in a hospital setting, where labs, imaging, and more tools are at the clinician’s disposal for immediate referral. “We’re more limited in what we can provide in that setting,” she says. “The evaluation is the same. But the goal for us as providers is to find out if it can this stay in this setting or does it need to go on to a hospital.”

Using technology in healthcare to better reach patients

In her experience, the PA sees advanced practice clinicians like her having two challenges in communicating to patients in the urgent care setting:

  1. When the urgent care is used for chronic condition visit: Properly instructing them on appropriate follow-up so that they do return to the clinic should they require continued treatment or should a condition worsen.
  2. When the urgent care is used for episodic visit: Helping them understand the nature of their condition so that they don’t feel that they were improperly treated – for example, when patients don’t understand why they aren’t being given antibiotics for every ailment.

Having access to quality patient education materials becomes essential for clinicians who need to make a strong impression on patients in a limited time.

CDS in healthcare: Is there a way to design it for ambulatory and urgent care?

For a PA or NP working in these increasingly busy outpatient care settings, Clinical Decision Support has always been an important companion tool. But, as patient volume increases, the way advanced practice clinicians engage with CDS resources is changing, the PA observes.

“They need to be able to answer their top questions within a matter of seconds. And often the best way to provide that information to PAs and NPs on-the-go is through charts and graphics,” she explains.

To illustrate, she notes that a common issue a PA in an urgent care setting might need to look up is confirming a diagnosis of acute bronchitis versus pneumonia. In an urgent care setting with patients waiting, she likely would not have time to read a lengthy or even a summarized description of the differences to confirm her diagnosis. “If I can quickly pop up a graphical answer to say, ‘OK, what were the major differences and how can I confirm the correct diagnosis?’ I can have the answer in seconds.”

It was the needs of clear communication among clinicians that prompted UpToDate® evidence-based CDS system to further a project aimed at redesigning clinical content to be more accessible in high-patient-volume settings such as urgent care and ambulatory centers. The content also promotes communication between and patients.

Some of these updates include:

  • Adapting topics into graphical presentations or charts for fast, easy viewing
  • Direct drop-down quick links to search results to eliminate having to scroll through full topic articles to find answers
  • Direct links to clinical pathways to assist with diagnosis, triage, testing and treatments

“Clinical pathways have been an exceedingly helpful tool for PAs and NPs during the pandemic when so many patients have had difficulty getting appointments to see specialists and have diverted themselves to the urgent care,” she says. Pathways can help the advanced practice clinician better follow evidence-based treatment plans for patients with comorbidities and specialized conditions.

Will urgent care continue to grow?

Trends point to an ongoing expansion of urgent care as healthcare businesses continue to invest in them and patients continue to rely on them. The PA notes that some of that reliance “depends on where you live, how much access you have to healthcare, and what insurance options you have, if any. It makes a big difference.”

According to Forbes, more than 130 rural hospitals have closed in the past decade with more than 450 still in danger of shuttering. Additionally, the emergency department at many of these and other hospitals is estimated to serve as the primary access to care for around one-fifth of Americans, mostly uninsured and resource-limited populations.

“When I worked in urgent care, we offered discounts for annual physicals for your kids to go back to school for people with limited health insurance options,” the PA says. “Your access to healthcare makes a huge difference on where you’re going to go for your care.”

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