Prime movers: Advanced practice professionals in the role of stroke coordinator

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The Veterans Health Administration (VHA) annually admits approximately 6000 veterans for inpatient treatment of acute ischemic stroke (AIS; Ross et al., 2011). Each year, acute hospital care for new strokes costs an estimated $111 million, with an additional $74 million for postacute inpatient care and $88 million for the 60,000 outpatient visits that occur in the first 6 months poststroke (VHA Stroke QUERI, 2012). AIS is a time‐sensitive condition where emergency treatment is critical for preventing long‐term effects of stroke, which include moderate functional impairments and long‐term disability. In 2011, the VHA issued an AIS Directive (Department of Veterans Affairs, 2011) aimed at reorganizing and standardizing acute stroke care delivery across Veterans Affairs medical centers (VAMCs). A formative evaluation of the Directive suggested a need for systematic nurse training and coordination among providers from different services (Damush et al., 2014). Because higher quality care is associated with coordination of care across settings and providers (McDonald et al., 2007), nurse practitioners (NPs) and other advanced practice professionals (APPs) may play a crucial role in facilitating quality improvements.
In large integrated healthcare systems, increased attention has focused on framing gaps in health services as opportunities for improvement (van Wijngaarden, de Bont, & Huijsman, 2006). For instance, forming teams dedicated to improving outcomes for stroke patients requires coordination between different disciplines that may include neurology, internal medicine, radiology, lab, pharmacy, and rehabilitation. Williams (2002) characterizes boundary spanners as individuals proficient with interpersonal relationships and as people who are considered “honest brokers” within interdependent systems. While the ability of professionals to cross boundaries or connect disparate groups has long been recognized in the organizational science literature (Tushman, 1977), limited evidence exists about the association of boundary spanning in healthcare outcomes. A recent review of boundary spanning in healthcare contexts defined boundary spanning as actions that bridge disciplinary silos, facilitate communication between different types of stakeholders, and cross professional divides to work toward a common purpose (Nasir et al., 2013).
Studies in the nursing management and implementation science literature have demonstrated how providers with nursing backgrounds are well suited to operate across disciplinary, service, and patient–provider boundaries (Abrahamson, Mueller, Davila, & Arling, 2014; Kilpatrick, Lavoie‐Tremblay, Ritchie, Lamothe, & Doran, 2012). NPs and physician assistants (PAs) developed as distinct professions following the success of military medics working under supervision of physicians. Collectively known as APPs, these two clinical occupations arose in the 1960s in response to demand for primary care provision. Whereas PAs typically train in medical schools under the supervision of a physician, NPs and clinical nurse specialists fall into the broader category of Advanced Practice Registered Nurses (APRNs) with training in nursing schools. Future projections suggest that the number of full‐time NPs alone may increase 130%, from 86,000 in 2008 to 198,000 in 2025 (Auerbach, 2012). There were 93,098 PAs certified in 2013 (American Academy of Physician Assistants, 2014). In addition, projections indicate that APPs will assume greater responsibility for patient care compared to physicians as a response to shortage in duty hours (Cooper, 2007; Moote, Krsek, Kleinpell, & Todd, 2011; Sargen, Hooker, & Cooper, 2011). In 2016, the VHA proposed granting full practice authority to APRNs in part to meet projected staffing shortages (U.S. Department of Veterans Affairs, 2016).
The role of NPs and PAs in developing and coordinating VHA stroke care programs within an acute stroke care team can help demonstrate how boundary spanning operates in practice. Comparatively few studies have examined the role of APPs in inpatient medical settings despite their growing presence in hospitalist roles (Kartha et al., 2014).

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