And I will start us off by introducing Susan Stanton, who is a nurse practitioner at the Cleveland Clinic. Hi. Thank you for having me today. I will explain, but I'm actually a physician assistant at the Cleveland Clinic. And it's absolutely fine, but you will learn the differences today in my presentation. So I will be talking about the different roles. I was asked to kind of go through the different advanced practice providers that can be utilized in the epilepsy practice. And I also think I have a unique perspective, because I am not only a clinical provider at the Cleveland Clinic for the last almost 13 years, but I'm also a manager. So I manage over 20 advanced practice providers within the Epilepsy Center, and 35 across other neurologic specialties. So I think I've done a lot of hiring. I've done a lot of onboarding, and I really understand what goes into this part of the practice. All right, I don't have any disclosures. So I will be defining the different advanced practice provider positions, and then also looking at the details on scope of practice, certifications, and practice models that will hopefully add value to the epilepsy team, and then ultimately provide better access to patients. And before I go into the first APP, which is CNS, I just wanted to go over, if you've heard APRN before, that's Advanced Practice Registered Nurse. And that's an umbrella term for all the different certified nurses that are out there. And so we're going to focus on two today, but just so there's a complete representation. The other two are a Certified Nurse Midwife, and then also a Certified Registered Nurse Anesthetist. But the two that are relevant to epilepsy practice, the first is a CNS. So this is a graduate level registered nurse. They look at three spheres, the patient, the nurse, and the organization. And when they go into their schooling, they pick a pathway, which is either adult, pediatrics, or neonatal. And really, this is a type of position where they focus on policies, education, research, teaching, consulting, and management. I'll give examples of that in a couple of slides. So they do need to go through a graduate level program. They do core coursework, and then a minimum of 500 supervised clinical hours. They have to pass a national certification exam. They do have to keep a state CNS license, and also their RN license through the nursing board. And then we'll talk about most of the time they would have a standard care agreement with a physician. To keep up their license, they have to certify every five years by doing 1,000 clinical hours, 150 continuing education units, and then also an additional 25 hours of pharmacology. So I thought this would be a nice way to look at this. You're going to see, hopefully through my presentation, that every state is very different in what different advanced practice providers are able to do. So knowing your state laws are really important when choosing who you might want to hire into the position. For CNSs, most can work independently. They don't need a collaborating physician. You can also need a collaborating physician. Or interesting, I learned that not every state recognizes CNS as an advanced practice provider. And I've only actually worked with one CNS in my clinical role. And when that provider, what they did for our center is they were very heavily involved in standard operating procedures. They would create education for the nurses. She did a great video on how to do a seizure interview. She was heavily involved in quality. So did not work in the clinical role, did not prescribe. But she really elevated the care that was delivered and the education that the center received. A clinical nurse practitioner or certified nurse practitioner is also a graduate level registered nurse. There's more certificates or pathways that you would need to pick through the schooling. So it could be by age, like family, pediatric, adult, or neonatal. And there's also different pathways with emergency, psychiatric, or women's health. So pretty pigeoned into a different area. And on top of that, once they get their certificate and become a nurse practitioner, then they do further certificates. So you could have a family nurse practitioner that went back and got a second certificate in psychiatry. So you'll see a lot of letters after people's names with the extra certificates that they've completed. I won't go through this top part again, because it's the same as CNS's. But the only difference is that they're recertifying every two years. And looking at the state authority, a majority of states allow independent practice for nurse practitioners. And so the caveat is usually they have to have enough training in the specialty they're going to be working in before they do independent practice. And then other states do require a nurse practitioner Other states do require a supervision agreement with a physician. And some even have kind of restrictions of what you can do in practice or what you can prescribe. That's the most strict states. So I'm rounding it out with physician assistant, which is soon to be a name change to physician associate. It's not finalized yet, but it will be changing, I believe, in the next year. So this is a graduate level degree, a very different. We don't go into certificates. We learn to treat all ages. We work in primary care, surgical settings, and our specialty based on what interests that we have. And really have an option to move around in specialties throughout our career. There's also post-degree fellowships, not only for PAs, but also the advanced practice nurses. So for example, when I graduate from PA school, if I wanted to be in a subspecialty, I could go into a fellowship like neurocritical care. Or Cleveland Clinic right now is developing a neurology fellowship for advanced practice providers so that the year after graduation, they're going to rotate through all the subspecialties and get a really great foundation to start working. PA requirements, usually you start with a bachelor's degree, preferably in a health related field or science. And many PAs do pre-med prior to going to PA school. You need, this is a difference between the nurses and the PAs, is nurses most of the time don't get nursing experience prior to NP school. And so they've got clinical care under their belt. Whereas PAs, if you think about the medical school route, you're going right into clinicals. And so prior to starting PA school, we do hands-on experience or patient care experience. And that can be done in a variety of shadowing opportunities or working as an MA in clinic for a certain amount of time prior to starting school. So you do a master's degree. It's a two to three year full time PA program. So nurse practitioners and nurse specialists, sometimes they work throughout school as a nurse. PA schools, you're not allowed to work during because it's a 15 month didactic phase, Monday through Friday all day. And then after the didactic phase, you do 2,000 clinical rotation hours. Those are done within, most of the time, eight required specialties. So we rotate through internal medicine, infectious disease, emergency medicine, pediatrics, surgical, psychiatry. And then we do get to pick two electives. So for example, in my PA training, I did neurology as an interest and then also surgery. And then you need to pass a national certification exam and get a state license through the medical board. Another difference, the nurse practitioners and the nurse specialists are through the nursing board and we're through the medical board. And most states do require supervision agreement. I'll show you that map in a minute. Another big difference is, I think this is the only professional master's degree medical specialty or profession that you have to recertify. So every 10 years, I need to take a board exam. And even though I'm subspecialized in neurology, it is across all of medicine. So I'm just starting that this year again. So pray for me. But they actually just made a new program where you have an option to sit for a test year nine, or you can do, it's nice, over three years, you do every quarter a certain amount of questions at home, which is what I opted for this year as a mom and busy. So looking at the map, you'll see that most states, there's only a few in the green that don't need a supervision agreement. Most states require supervisor agreement with a physician or the physicians in the practice. Okay, so hopefully, that's a good understanding of what the different roles are. Now prescribing medication is a huge part of our practice. And so that varies state to state. There's rules around prescribing, administering, dispensing, and procuring the medications. And what I found, and there's great charts online about it, but most states allow full prescribing, including controlled substances. You do require a DEA in each state. You have a license and plan to prescribe in. And you do need to check your controlled use on the state registry. So for example, we use ORS in Ohio. The example from Ohio, since that's where I'm from, CNSs, CNPs, and PAs all have full prescribing of category two through five controlled medications. We used to need to apply for a separate license for prescribing, but that probably six or seven years ago became part of just your license when you become a PA or a practitioner. All right, salary versus billing. So what is this going to cost your practice? I looked at the average. There's obviously very large ranges of what NPs, PAs would make. I found the average to be about 120,000. Depends on the years you practice, your specialty, where you're located. Obviously, cost of living. For billing, so if you do a procedure, you see a patient and a staff physician would bill and get a certain rate, an APP would get 85% of that same bill. And I looked up, just to give some examples, I work obviously in a large institution. We have a lot of outpatient and inpatient APPs. I looked at some of our senior APPs, just to give an example. One of our providers does full inpatient Saturdays, Sundays, and Mondays. And her billing in 2022 was 1.4 million. And this year, as of October, was 1.1. Again, that's what you bill, not what you are reimbursed, right? Outpatient, senior APP, this is a completely remote APP that's been with our practice for over 30 years. She does all telemedicine. And last year, she was 860,000. And this year, as of October, she's already up past a million in billing. Models of practice. You can think about this in a couple ways. I like to think about outpatient, inpatient. I have APPs that do both. Some of us rotate, some of us are one or the other. In the outpatient practice, you can have autonomous clinic. So I could see, in my practice, we do all established patients, but there are practices where people see new. And we have paired clinics, or shared medical appointments with staff and other providers. You can think of a specialty clinic. So you could have an APP that specializes in pregnancy clinics or neuromodulation. And then, this is very interesting, but at Cleveland Clinic, we do ambulatory needs. So there's weeks where I am in the boxes, covering all the doctors' telephone messages, refills, letters, calls that come through. So I can work at the top of my scope, and it allows them to work at the top of theirs. So they're off reading EEG and doing patient management conferences. Obviously, we collaborate for the more complex questions that come in. And then inpatient, you have EMU patient care, if you have an EMU. So we do our HNPs, our progress notes, or all of our discharge paperwork procedures. We put in sphenoidal electrodes, we adjust the VNSs, and then acute seizure treatment of patients in the monitoring units. If you have BEMS, or you do consult service, we can be a part of that. And then I like to say, like, you know, the sky's the limit. You can think of day's team. We've expanded to night's coverage. We have weekend coverage. So APPs are staffing our EMUs 24-7 every day of the week, every time of the day. So what to consider. If you are looking into having an APP join your practice, think about the age of your patient population, right? Because APP degrees are different. You might have a pediatric nurse practitioner that would not fare well for an adult patient population. Previous experience or interest. Obviously here at AES, you have a lot of APPs that love epilepsy, but when I go to hire someone, that's very small amount that would apply that have epilepsy experience, right? Maybe some neurology experience. I might have some neurosurgery people. I might get someone from cardiac that's just looking to change positions. I might get a new grad and I love hiring new grads. Okay, so don't be afraid. I know that there, you know, we don't have the background of the training that staff physicians have. You train so much, but we are eager to learn. And if you have the right person to join your practice and you give us the time that you would share with a resident or a fellow, we will pick up and hopefully have a really good collaboration moving forward. You need to think if you want them to work independently or if you wanna collaborate throughout practice. We've done some great paired clinics that bring in double the patients and the staff kind of pop in and out kind of like a fellows clinic, which is really rewarding to both. It's a fun day for both of us. And then think about salary and CME needs. Obviously we need to continue our education just as everyone else in the room does. So giving us the time and the resources to be able to do that. So in my practice, we also, and we're just rounding out the last couple of slides. I have APPs that do everything on this list. We have research APPs, get time for research, publishing, abstracts here at AES, quality improvement. We have a nurse practitioner that leads our quality, is the quality director of the epilepsy department at Cleveland Clinic, which is really amazing. Educating, mentoring other APPs. We're looking into EEG reading and coordinating the EMU patients. Leadership and community outreach. We get involved in the community and the different associations that our patients are seeing. So to conclude, this is a means to increase patient access. We hope to optimize and elevate the care that we can provide to patients. Remember, it's a subspecialty, so we have to give the time and the engagement in order to learn the specialty, and you hope to retain that person that you spend your time with. Each APP has a different training and education and interest. So, you know, tuning into what they might be able to provide to your patients and really get to know your applicants in the state laws. I did a lot of research just on like the sites to get the information that I provided to make sure we were up to date on everything. And I just really want to thank, the Cleveland Clinic is an amazing APP forward institution. We have councils and leadership that's really amazing, but specifically my epilepsy department is so wonderfully, what should I say, supportive of the growth of our APPs. So I really thank Dr. Madhnaj, I'm the director, and all the staff that I work with because they encourage me and they support me and they give me the time to be able to grow professionally. Thank you. All right.

Advanced Practice Providers

Epilepsy Care

Physician Assistants

Cleveland Clinic

State Regulations