appreciate everybody joining. I'm excited to present to you today the 2023, although I know it's 24, but it's the report from 23 that probably many of you took engaged with us in as far as the survey related to APP utilization. So what I'm gonna spend the next 30 to 45 minutes or so is walking you through those findings, maybe adding a little bit of color based on some of my experiences and the evolution. And I'm excited to say we've had a pretty good evolution when it comes to team-based care. And then highlight maybe some continued opportunities as we move forward in our delivery model. So a little bit of homework or housekeeping as far as our webinar. So you can see the links below. There's the Q&A, and then there's the link in the chat where you can access the presentation slides. So you can have access to all these slides. Spoiler alert, they are basically out of the report. So at the end of this, I've got a slide that has the links for you to download the full report. And so this really is just a summary of that. So you're welcome to the slides, but I would also encourage you to download and look at that full report that was published, I think, back in December. All right. So my first is just a huge thank you. We had 106 submissions this year, which was more than any of the previous years and continues to grow almost exponentially. I think we go up by 20, 30 responses every year, which just makes this data richer and creates an environment where I think we can kind of lay a stake related to what we're learning and what people are doing and what are some of the more common kind of where we live in the median, if you will, as far as the way we utilize the APPs. You can see that I think represents the country pretty well. Maybe this next year we'll look a little bit more for those from the West, but our Midwest, our South, our Northeast, I think we did a pretty good job as far as representation. In general, the team-based care model is growing or the use of APPs is growing. So if I look back and this data came out of our MedAccess data from 2022, we are in the process of collecting 2023 data because remember we do that annually in the first quarter of the following year. So this is 2022 data, but as you can see our APP to physician ratio has continued to grow. Cardiology is the light green and over the last five years, we've gone from a 0.5 APP FTE to physician FTE. So for every physician, you had a half of an APP or one APP to two physicians up to 0.62. So we're at almost two thirds. And then if you look at cardiac surgery, we've seen a pretty good growth there. That's the dark blue line. And then overall from a vascular surgery perspective, we've seen a decent trend there as well. I will say, and we're gonna talk about surgery towards the end. I think one of the big drivers around the cardiac surgery has to do with a lot of the CVICU management. And I'm seeing a number of teams being put together to manage those post-op patients that increases that APP to physician FTE for those programs. So a lot of work happening in that space. The first kind of section I will talk about is the leadership and incentive. So I'm always curious and actually not just curious because I actually think it's an imperative way we set up our organizations is has to do with that APP leadership structure. If I go back to part of the report that I put together, not this year, but last year, one of the things that I talked about in that report was APP attrition and turnover rates. And our literature tells us that strong leadership or lack of strong leadership correlates with turnover. It's just one of the things that drives turnover if you don't have strong leadership. And one of the things that I have found over the years and now advocate for is that APP leader, APPs reporting to other APPs. Now, from a size perspective, I think, and I don't have it on here historically, but I've really said, by the time you get to about 68 APPs on your team, it's time to think about a team lead. And it's not a full-time role. It's a 0.2, a one day a week, or even an afternoon a week where they're given some admin time, but it gives the team a voice. And so, although I don't have the year over year trends here I will say that we're seeing more and more in this APP leadership structure where APPs are reporting to APPs. So we're at greater than 50%. Now, the title of that role is different. And a lot of that has to do with organizational size as well as just the titling within organizational structures. And a lot of that's just kind of driven from your HR and the way your system is set up. But you can see here, we've got APP lead, APP manager, APP director, APP supervisor. In some cases, the APPs directly report to the physician leader and other cases they directly report to administrator. Now, again, if I go back to what I typically advocate for I like to see that APP leader create a direct line to both an administrator and a physician leader. And that way we've got direct clinical leadership and we've got direct administrative leadership, but it funnels through that APP leader. So it creates an environment where the APP team feels supported by someone that understands them, understands their professional role, advocates, but the flip side also advocates for the organization and the important role for the APP within the organization. So I think there's a lot of value there. And certainly I go back to that attrition. If we don't have our leadership structure right and the team doesn't feel or isn't supported, that just creates an environment for some morale issues. I think this role is really important no matter what the title is or how it's set up. Now, APP compensation. That's always another big question that we get. And we've provided you here again, five years worth of data. So if you can see the bars, but you can look down and see the actual data. This is median APP compensation. We broke it down by the different specialties, but I'll focus on cardiology for right now. You can see that year over year, that compensation has continued to grow. And we actually saw a 13% rise in the last five years. Now that is consistent with national trends as far as APPs across other specialties as well. And I think we probably see that in some of our other healthcare professions as well. From a specialty perspective, you can see that there has also been growth on the cardiac surgery. They're up to the median for that in 2022 is 149. And for vascular surgery, kind of seeing a little bit of growth, but not nearly as much. Some of that might be a result of the fact that our sample size on the vascular surgery side isn't as large as what we see in the cardiac surgery or even cardiology. So some of that variation there may be more related to our sampling than actual true trends across those years. And then we've brought in the 25th, 50th, 75th, 90th percentile, so you can kind of break those out. Now this is at a national level. We do have the ability to break this down at a region level, like a Midwest, South, East, Northeast. So if you have any additional questions on that, go ahead and reach out and we may be able to break it down further to give you something to compare to your more local markets. The other piece of this is that we still occasionally get questions related to, is an APP role an exempt salary position or a non-exempt hourly position? And 93% of you said they live in that exempt salaried environment for you. So then we ask, what does that incentive look like? Or how is that earnings? How are those earnings? What's the architecture behind that? So how are they organized? And what we have here is the percentage of APP earning potential related to incentives. And the majority of APP earning potential is still in that base salary. So 55% of you said that there is some additional incentive, but it's less than 10%. 10% said 11 to 15%. 13% of you said 16 to 20%. And 5% said greater than 20% of that APP's earning potential is in addition to the base salary or outside of the base salary. Some would maybe call that at-risk dollars, things you have to earn outside of just showing up for work. So what are some of those incentives? And you'll see here, we've got call pay, productivity, and I'm gonna get into a little bit more of that here in the next couple of slides. Some incentives related to some citizenship metrics. And then I asked the question about the CME dollars and the CME days. Most of you are providing that for your teams and I've got the breakdown here as well. Now, one of the questions that we had in our data team, thank you very much, put together this analysis. And the question was this, is there a correlation between organizations that pay for productivity and overall RV, in this case, RVU, which not my favorite, but it is mostly the easiest thing we have to measure for sure, RVU earnings or RVU productivity and overall compensation. So we kind of broke it down by the different quartiles of RVU earnings, as well as the quartiles for overall earnings. And what we found was there's no correlation. So when you report us your data, there's no correlation for those APPs that produce more RVUs and where they fall on the compensation kind of continuum or compensation range as of right now. And that I actually was not surprised by this, as I'm gonna show you here in just a minute. Some of us aren't even measuring RVUs. Some of us are using APPs and more of coverage models. And then some of us, although measuring, it's still really challenging to allocate or attribute RVUs to the truly performed work in a split shared environment or an incentive to. So there's, or incident to. So there's just some challenges in our ability to measure. And so actually I'm kind of glad to see that there isn't a correlation, because I don't think that our RVUs necessarily, although it's the best thing we use right now to measure, they don't always necessarily truly, I think, show the workload. And I'll explain more of that in just a minute. All right, from a CME benefit, you can see here 65%. So the majority of you said that your current CME benefit is somewhere between 2,000 and 3,500. There were about eight programs, because we had a little over 100 take the survey. Eight of you said 3,500 to 5,000. And then 27%, or probably right around 27 to 28 of you said it's between 1,000 and 2,000. I do think this has gone up a little bit. I don't, again, I don't have the trending data in here, but there was a time where a lot kind of sat between that 1,000 and 2,000. So to see the majority of you say two to 3,000, I do think that number's going up. And then days provided, 76% of you are providing five business days or five full days for CME activities in addition to other kind of paid time off sort of benefits. So the good news with that is that means that you're valuing professional development. And I do know that's a big satisfier for the team. You know, we typically go into being an advanced practice provider as lifelong learners. And so to have those opportunities is a really, really nice benefit. So it's great to see that. All right, productivity. So the question was, if you are measuring APP productivity, what are you using to measure? And 75% of you said that you are measuring RVUs. Now there's some overlap here. Some of you are measuring more than one thing, and that's okay, actually. I think that's actually a really good thing, especially given that sometimes some of the patient, direct patient-facing work doesn't always have an easily attributed RVU with it. But 75% of you said that you are, in fact, keeping track of the RVUs. 45% said patient encounters, the number of patient encounters. And 14% of you said that you are keeping track of patient contact hours, which again, for APPs, that's usually like the clinic schedule and or if they happen to be in the hospital, the time that they are responsible for direct patient care in the hospital. I pulled in kind of the most common or median, I guess, if you will, responses for each of those areas. The full information is in the larger report, but for the RVUs for targets, 39% of you that are measuring RVUs and have a target, have a target of greater than 3,000 RVUs for the APPs. Like that's how you know you're successful is if the APP is generating more than 3,000 and 39% of you said that's your goal. For encounters, and this is at a daily level, 14 to 16 encounters daily is your goal and 37% of you described this as your goal. And then patient contact hours was 37 to 40, 47, of those that are measuring patient contact hours, 47% of you said that is 37 to 40 is the number of hours that you would consider having met the goal or being successful. So I think those are all really helpful to kind of understand workload expectations, what's being measured and what are your options for measuring and then starting to develop some soft benchmarking around those things as far as expectations. So let's talk about RVU a little bit. I talk about it every year and it is a mixed bag. It's not, I say this every year, it is not my favorite. It's not my favorite for physicians either, but it is a way that you can objectively quantify the provider level work that's being done as long as you're able to take into account the work that might fall under split shared that ends up being billed under the physician NPI number, the work that falls under the incident two that might be billed under the physician NPI number and the work that occurs related to global billing. So for those of you that are in the surgical worlds or some of the procedural worlds, there's some global billing in there where a followup visit, you would not have necessarily an RVU associated with, so are we able to keep track of those? On the inpatient side, we may have some discharge visits, things like that that would not be billable under a, because it's under global. So I do think it's important to when you utilize these numbers, compare it to what you're able to track and the type of work that you're asking your APPs to do. The flip side, so I'll start just by saying it's not a perfect way of measuring workloads. However, it is a way to measure workloads and when we start to think about defining objective expectations and as long as you take into account the type of work that you're asking your team to do, I think it's fair to develop thresholds around this and what you expect. And so the good news is we have been monitoring this. In this case, we went all the way back to 2015. I started with MedAxiom in 2014. And when we first started looking at this, the average, so the median RVU, so not average, median, median RVU productivity per cardiology APPFTE was 351. I will say there was a lot more incident too happening back then, and probably more split share happening back then. So this may have been more of a product of lack of an ability to capture. But I also say, and I was actually on a call earlier today and I quoted, and I'll quote you again. I have now, because I've been doing this for a long time, I have now done work in 43 out of the 50 states. I've been in a lot of your programs and I know that there is and continues to be, there was and continues to be some significant opportunity in the way we're used to assure that we're doing provider level work. So I do think there was big opportunities year over year. I have to say, I'm a little excited to see us finally up to 1600, 1700. Now, if I go back to what you all reported that 30 some percent of you said your goal is 3000, I still think we're far under, but there's a lot of considerations that need to be taken into account. And you all have a story, but here's some good data that you can kind of compare back to your program and kind of decide what's reasonable for you and where should you fall. In the larger report, you will see our typical slide where I kind of pull in the capacity for office-based APP. And that capacity still sits in the high 5000s to close to 6,000 RBUs, if they're billing under their own NPI number and seeing somewhere around 15 patients a day for typical cardiovascular type patients for the type of subsequent follow-up visits that you would see for those patients. So 6,000. All right, other big hot questions. And we're gonna continue to ask this question every year because it still comes up. What is the typical APP scheduled hours versus what do we expect out of our full-time APPs? How many hours a week should they be working? And we still see a little bit of a difference. We ask the questions in two ways. We ask, what do you schedule them? And then we ask whether they're actually working. And you can see the majority of these, there's a gap. So 85% of you say we schedule them at 40 hours, but 41% say they're actually working probably closer to 45 hours. So you can take a look here. I get it, and we're not shift workers. And I am, again, that's another area that I advocate for. We're not shift workers. We're professionals, we're part of the professional clinical team. You work until the work is done. At the same time as administrators and leaders, our job is to make sure that our expectations are reasonable. And when those workloads start to go significantly above our expectations or what we have on paper, we may need to think about reorganizing that team differently or adding additional people to the team. So I think there's some workforce planning too that can happen with some of this, as well as just managing expectations and understanding kind of the workloads and the different considerations there. All right, now we're gonna split into kind of utilization patterns, and I'm gonna start with ambulatory. I'll flip into acute care. We'll do a little bit of surgical, and then this year's special consideration or specialty care program, I chose heart failure. So we did EP last year. This year we did heart failure. So from an ambulatory perspective, 99% of you are having your APPs do routine follow-ups and post-hospital follow-ups. 94% are doing post-procedure visits. 87% are doing urgent patient needs. 77% are doing telehealth. 74%, they're involved in some form or another with the vice clinic patients. 44% are utilizing them in your specialty clinic areas or specialty clinic populations. So lots of very good information here as far as the types of patients that APPs are currently seeing in cardiovascular. And again, I think just kind of compare this to your current use models, and are you taking advantage of some of these good opportunities to use APPs? The next question had to do with the schedule. So what kind of time is allocated for them to see these patients? 54% described 30-minute visits, and 6% say 40-minute, 10% said 45, and 3%, which is probably about three programs, said 60. Now, I did not break in down types of clinics. This was all kind of in general, was a generally asked question. And so that might be why there's some variation, but I would also say this is one of the areas of significant variation that I see is the amount of time allocated. So I've seen 20 minutes, like several of you, 19% said 20 minutes, and 13% actually said 15 minutes. So kind of give you some perspective around what other places around the country are doing. I've always said, though, there's a story behind all the data points. And so when people ask me, how much time should I give the APP to see patients? Is it 30 minutes? Is it 20 minutes? Is it 45 minutes? I say, yes. And I say that through, it has a lot to do with the support. It has to do with, do we have our charts prepped? Do we have, what types of patients? Are they seeing patients they already know? Are they seeing all brand new patients? Are these urgent patients? Are these specialty clinic patients? And so I think you have to really take into account some of those factors. However, in a general cardiology scenario, where we're gonna assume there was an MA that roomed their patient, the chart was prepped, and they are in a circumstance where many of the patients they're seeing are patients they have seen before, 30 minutes seems very reasonable and matches your responses with 54% of you saying 30 minutes. The next question then was how many patients per day? And this one had a little bit wider kind of span of responses. So 36% of you said 14 to 16 patients, 25% of you said 11 to 13, but 18% of you said 16 to 18. So you kind of got that range between 11 and 18. If you averaged all of that, I think you would come pretty close to that 14 to 15 patients a day. So if you start to do the math on a 30 minute visit and an eight hour day with some time and break off at lunchtime, you've got about a 15 patient day. So I do think that between these two metrics, that's probably where most of you are landing. This is 30 minutes, 15 patients a day. All right, clinic duties outside of just seeing patients. And I shouldn't say just, because the majority of the work that's happening now is seeing patients. But peer to peer for prior off. So utilizing your APP team to make those phone calls. 65% of you are using APPs to support chronic or principal care management services. So I'm excited about that. I think that's a great role for an APP. I also think that's a great way to deliver care to our higher risk patients and a great way to keep them not only out of the hospital, but I would even say out of your clinics and create an environment where you can keep track of them and manage them and support them without using an exam room, parking lot in your waiting room. So it's a great way to deliver care and a really nice role for an APP to be part of that management model. 65% of you said that they're working in basket, but they're doing theirs. If you flip down, 52% said they're doing theirs and the physician. So they're attached to the physician in basket and managing that information as well. 62% of you said they are interpreting EKGs. What I typically find with that when I'm kind of out and about talking with people is that they're interpreting the ones that they order. They're not necessarily part of your interpreting pool. In fact, I don't think I've ever seen it where the APP is part of the interpreting pool. But if I see Mrs. Smith today and order an EKG, I read that EKG. In some cases, it's overread by the physician and the physician drops the charge. In some cases, the APP will drop the charge. There are some payer nuances with that as well as potentially some licensing stuff. So you have to look at your licensing kind of scope of practice as well as maybe what your local payers or even Medicare, your administrative carriers, what are some of their rules around that? So I assume that when you say 60% of you are having your APPs do EKG interpretation, that doesn't necessarily meaning that you're all billing under the APP NPI number. Many cases, they're being overread and then billed by the physician. Device interrogation interpretation. 44% of you said that you've got APPs doing some of that work. Again, my narrative there would be, it's typically not that they are a full-time device clinic team member, but they're doing that work as part of their hospital-based work or maybe in clinic if they have patients that come in with devices that are having a problem, they have the skillset to be able to interrogate that device and understand what's going on. It's not that their job is full-time or even significant portion of their job doing that work. That's part of the device team. 44% of you utilize them for remote patient monitoring services. Again, I think that's another great opportunity similar to the chronic care management. And then 42% stress test performance slash supervision. Again, after a couple of years ago, we do have the ability to supervise stress testing in a direct supervision perspective. So we do not have to be in the room performing the stress test, but we can be responsible for the team that's doing that and supervise that team. So for those of you that have outreach areas or have clinics where you don't have physicians there every day, this is a great opportunity for the use of your APP team. And then don't forget about the rest of the team. So I mentioned this earlier when it comes to some of those time allocations, but 96% of you said that you use an MA for rooming patients for your APPs. That 67% said there's an MA that may be used for other reasons, maybe patient callbacks or supporting some of the in-basket work. 62% of you described RNs that are working along with those APPs on the in-basket management or patient callbacks. And then 4% said RN-LPN triage functions. All right, another big question. And I split this up in both ambulatory and then I asked it again for the acute care team. So for those of you that have acute care only APPs, but in this case it has to do with ambulatory call. Only 19% of you said that your APPs are taking any call right now. And of those 19%, 80% of you said that you're paying them through a shift stipend. The other 20% would pay them through part of their salaries, just part of the expectation, part of the work that they do for their typical pay. But again, less than 20% are taking call right now on the ambulatory space. And then you can see the breakdown below related to how much pay shift stipend. Again, this is ambulatory call, so they're not expected to go into the hospital. They're just answering, as you can see, patient calls 80% of the time. 67% of the time they're doing hospital floor calls. A small portion are taking ED calls. And then there's a few that are other related calls. So, but again, not a huge number yet. Although I do think for sizable organizations and when the expectation is managed and compensated, it's not necessarily an unreasonable utilization of your APPT. All right, acute care. So flipping over to the hospital, typical responsibilities, and this isn't that much different. So rounding 97% consults, 82% admissions, 78% discharge planning, 77% E&M billing. So they're billing for, some of them are billing for some of those services where maybe they don't fall under split shared. 55% are doing some care management work. I would describe that as care coordination. So they're making phone calls or setting things up. 36% have APPs that cover nights. 16% describe procedures. 12% describe bed management. And no, that's not a high number, but some of you have APPs that are, I'll call it floor-based. So they are based on a floor or in the ICU, and that is their 100% role. For some of you, you will use that APP to help manage the beds in that department or beds on that floor. So admitting patients, transferring patients, and just overall helping with bed management. It's not a high number, but I did wanna call that out, but that is a role that some of you are utilizing your team members for. And then again, on the acute care side, a very small percentage of you are utilizing those APPs for stress testing. Acute care tends to be more shift related. So earlier I said, we're not really shift workers, but there are, especially in a 24-7 model, and I've got that data here, I think coming up, you will have some level, there's a start and a stop time. And so what you see here is on the hospital side, 34% of you said that they work eight hour shifts. 35% of you said 10 hours, 15% said 12, 11% said no shifts, they stay till the work is done. So that tells me they're probably a day person, and once all the rounding and everything is done, then they can go home. And then 4% said actually greater than 12 hours. So that was just a couple of programs. Now, I put a subtitle on this data that describes coverage versus continuity. And I think that's one of the biggest caveats with the acute care teams is balancing flexibility and coverage. And making sure we have enough people on each shift and the need for continuity. And what I mean by continuity is this concept of days in a row. So for those of you that haven't spent a lot of time on the inpatient side, but maybe are doing some scheduled coverage or are looking at your models, I'm just gonna give you an example or tell you a story that I think will just drive home the point that I'm trying to make. Back in my clinical world, we used to work weekends. I think that we were like one out of four weekends, which is I think pretty typical at this point. So Saturday and Sunday, if I had not been on service all week and I go in Saturday morning, start my weekend, and maybe get handed a list of 25 patients, I can expect that to take me all day. And it's like I used to describe it as walking through mud because every patient I would have to go see, I didn't know them. And I've got, not only do I have to review the last 24 hours, but I need to review the entire chart. I need to read their history and physical. I need to read their consults that happen to be on the chart. I need to read all of the daily notes that lead up to my need to see them today so that I understand what's been going on. I might need to look at the labs. I might need to look at the procedures and the procedure notes and the imaging notes. It would take twice to three times as long to see patients that I don't know. So on that first day, I don't know any of them. So it's it takes a long time. When I would come in on Sunday, I literally when I left the hospital on Saturday, knowing because we did 12 hour shifts, knowing that I was coming in the next day for a 12 hour, I literally felt like my weekend I had done the bulk of the work on the first day. Because when I came in the next day, 80% of those patients, given that I probably had a few that went home and maybe some new admissions that came in overnight, were patients I had already seen, you could cut the work down by almost two thirds, because it was my note from yesterday that summarized all of the different events that led up to me seeing the patient yesterday. So today, all I had to do was to see what happened in the last 24 hours, see the patient, do the note and move on to the next patient. So if you think about a coverage model where your APPs work a day on Monday, then they come back on Thursday, and then maybe we work Friday, or maybe we do Sunday. Every time you disrupt that those days in a row, you add more work. Now the balance is sometimes it's hard to work four or five days in a row. And people like the lifestyle, we need Tuesdays off, or we need this off. So I guess what I'm saying with all of this is as you think about your acute care coverage model, for those of you that have kind of a rounding service and have APPs that only work in the hospital, the more you can line up their days in a row and create continuity across their role so that they're seeing the same patient day after day, that will drive an incredible amount of efficiency. And I would even see care gaps because we know that one of the top reasons why we miss things is because the number of handoffs. And so the more continuity that you can manage, the less likely things will fall through the cracks. But the more handoffs my person to the next day or my note to somebody else's note, that's when things get missed. So anyway, a little bit of my soapbox, a little bit of my two cents. But I do think it's an important principle to think about when it comes to your inpatient teams. All right, call 28% say they take call remember 19% said that on the ambulatory side, acute care is 28%. What kind of calls do they take? So it's almost the exact same breakdown in patient calls, hospital floor calls, ED calls for some of you. We also asked this number of questions related to ICU responsibilities. And so in this case, you'll see that a number of you when your APPs work in the ICU, they will have rounding consults, direct patient care management, admissions, and billing against similar night coverage. 54% of you said they we have night coverage, 52% say do procedures for probably line management, line placement, and then a little bit more here related to bed management, where they're actually assisting and managing the throughput of those patients in those ICU departments. Workload wise, you are all over the place. So anywhere from four patients per APP to greater than 10 patients per APP. Again, we're talking about ICU. So a lot of these patients were rounding twice in the same shift. We've got, you know, issues happening, monitoring closely. The other thing that I think goes a long way into your coverage needs are is your nursing, the stability of your nursing team. For those of you that unfortunately have had a lot of turnover in your ICU nursing staff, that creates an environment where you have to have stronger APP coverage to manage that and versus just because of the seasonness and maturity of the inexperience, is what I'm referring to, of those ICU nurses, and their ability to pick up on patients that are deteriorating. If you don't have that, you end up with probably deeper, stronger, more high resourced APP teams in those departments. A little bit on the scheduling trend. So for full time, 21% of you actually, you know, full time for you is 72 hours. 13% said 76, 57% greater than 80, and 9% said something different. The ICU shift length, you'll see a lot more of these are the longer shifts, which sort of makes sense. You have less handoffs for these critically ill patients. 30% of you said they're 12 hour shifts. 11% noted greater than a 12 hour shift. Then we asked a couple questions related to cardiac surgery, mostly related to responsibilities. 88% said that the CTS APP responsibilities include a first assist and the OR. 70% said line removal. 68% said chest tube removal. 57% said line placement and chest closure. 55% chest tube. 53% said second assist. And then 18% described some transplant harvesting support. So again, kind of for those of you that have CDOR teams, a good list of different roles and responsibilities. All right, last section is heart failure. So what we're trying to do is every year pick a different specialty area and ask specific questions to understand how the APPs are utilized in that space. So for this year, it was heart failure. 83% of you said that you use APPs in your heart failure programs. Right up there with EP at 82%. You can see the breakdown for the rest. 63% for structural heart. 43% of you have prevention programs with APPs. 33% we're seeing more of this cardiometabolic and lipids. 27% other and 18% said cardio oncology. Other probably includes cardio OB, athletic, cardiovascular athletic needs. I'm trying to think of some of the others hypertrophic cardiomyopathy, we're seeing more of that we're seeing a lot in the genomics. So cardiac genomics or cardio genomics. So just again, those highly specialized areas. And although a lot of this is in the academic centers, for those of you that are in large regional quaternary care type programs, you are also standing up programs like this. And APP is a great way to increase the capacity of your physician and physician team. It's also a really nice satisfier for the APPs. And so some of you will use this as a professional growth strategy where you bring people into more of a general clinical cardiology role. And then as you add these new programs, that creates a internal recruiting opportunity for some additional, you know, kind of focusing in and feeling like you partly and help own some of this clinical care in these programs. APPs that work in a spaces get really, really, really good at these patient populations. So I think it's a great environment for team based care. So for heart failure, specifically, for those of you that are using APPs and heart failure, 90% of you said you're using them in a heart failure clinic, 61% said in a heart failure hospital service. For clinic, 100% said you're using them for follow up visits, 90% said urgent visits, 69% said telehealth visits, 41% said new patient consults and referrals, and 7% described in other. When we asked about the time allocation, and in this case, because there were some of you that they're seeing new patients, we went ahead and asked for both. And what you'll see here is that 54%, even in a heart failure space are still describing 30 minutes for those follow ups. And then for those of you that are doing new patients, 46% said we're giving them 60 minutes to do a new patient, which, for those of you that have worked or been part of a heart failure program, that makes sense to me, though these patients have long histories, there's a lot of information to weed through. They're on a lot of medications, typically there's, it's never isolated heart failure. So there's a number of comorbidities, a number of decision points, and a whole lot of patient education, as far as managing these patients effectively. So that concept, if I if I put those two together, and I say it's a 6030 template, in a typical heart failure clinic, because these are usually the sicker of the heart failure patients. That makes sense to me, and given the type of patient care objectives that need to be met. And then on the inpatient side or acute care side, you'll see rounding and consults, discharges, some admissions, and a few other which probably some procedural care, that kind of thing. So with that, a few key takeaways for you. So number one, median RVUs do continue to rise, I think I spent way too much every year, I feel like I spend way too much time on the RVUs. Problem is, we're all living by them. So I just want you to kind of understand the different considerations when it comes to APPs. But I would say if you haven't checked, where does your team fall? And does that make sense to you? And I think there's a couple good reasons for that. One, are we utilizing our team as providers and getting the full benefit out of their scope of practice, their license or education? Two, are we capturing all of the billing and in the revenue integrity portion of it? And then three, if a bunch of this stuff is happening under split shared or incident two, we want to make sure that at some point, our APPs are recognized for that work, and not necessarily penalized because of our coding and billing practices, even the appropriate ones. So just take a look at that. What's the story behind your RVUs? Number two, APP compensation continues to rise. Are you competitive? Now, this is what I would tell you again, based on my work last year and looking at APP attrition, we don't need to be the highest paid in the market. But we do want a respectable wage. So we do want a competitive wage doesn't have to be the highest. I will say where you run into challenges and you run into a lot of pushback is either where you're just, I mean, significantly below like double digit below. That's a problem. That's, you know, people, that's a problem. The second one is if you've got issues in other places, if you've got morale issues, if you've got kind of role responsibility mismatch issues, if you've got pushes related to workloads, and the workloads are really higher. So you know, we might say on paper, you're a full time 40 hours, but we're really asking you to work 50 or 55 hours. It's those environments where suddenly the compensation seems to be just the hot topic. And and seeking to truly want to be highest paid. I would also though say, even if you fix the pay, and you don't fix the other things, you're still going to have problems. So the pay isn't usually the underlying issue unless you're just really, really low. It's more related to those others environments. Most of us that work in cardiovascular are passionate about the work passionate about the patients. And we do it because we love it. We do want to be paid respectfully. So I think that's the take home. Number three, coverage versus continuity, I probably spent too much time on that. But I think there's a thing there, the more we're working with the same physicians, the more we're on the same teams, the more we're seeing the some of the same patients, whether it's in the hospital or in the hot and the outpatient setting, the faster we're going to be the more efficient we're going to be. So as you think about your models, do you have them set up for success? Or is it a plug and play, and I'm always seeing different patients, it takes longer. And then finally, APP leadership, I started with that I'm ending with that I truly believe it's imperative. And so if again, if you're struggling or finding you've got cultural challenges, or morale challenges, look at your leadership model. And maybe there's an opportunity or a need for some additional structure around that. So I am going to put a little plug in I've been we've been doing this work on the MedAxium side for again, well over 10 years on the APP, we have put a ton of resources into place based on what we know are your needs, because we've been working with you for a long time. And these are the things that you tell us, you can get a copy of this report MedAxium.com publications report. So go ahead and get the presentation from today. But please pull in the full report. I've got some additional kind of state of the team based care and cardiovascular at the beginning of the report that you might find interesting. Number two, our academy. So we it has been now six years we stood up our initial APP Academy offering to support you in your onboarding and continuing education for your cardiology APPs. I found out today we are at 999 enrollees or learners for our essentials course. If you look at our all in so we have essentials, we have acute care, peripheral vascular, electrophysiology, heart failure and cardio metabolic. All in I believe we're well over 1500 learners. And we work hard to keep those things updated and continue to build new content. And again, the goal is to create a standard learning environment for your team so that you understand what they've been exposed to. And they have easy access to the resources they need to do their jobs. It's not the end all be all you still need to teach them, nurture them, mentor them. But this is a really great infrastructure in which to start. So if you haven't looked into our academy, I would urge you to I think it's, I think it's great. We have an APP hub. So the medaxium.com backsplash APP hub, all the things that you heard today or saw today would be there. We also have case studies around good utilization, we've got a couple great white papers that talk about some of the principles that I covered today in addition to some other things for you to think about. And if you need some additional help with that, there's some other details in there for you as well. So with that, I am going to stop sharing. I have eight minutes and I will attempt to I don't know, Ari, if you can pop back on and help me with some of these. I don't know if there's questions or not. I have a hard time. I can't multitask very well. So we have no active questions right now. But as ginger member mentioned, at the bottom of your screen, you'll see that q&a button. So now would be the time to go ahead and submit your questions. We'll just give it a couple minutes. Again, tons of resources. At the end of the day, we built those resources because what we heard from all of you. So I would have to say biggest thing is just grateful to all of you for joining today even more grateful for those of you that filled out the survey. And even more grateful than that for those of you that have engaged with these resources and work with us to help build them out and continue to make them better. We feel strongly that team based care is imperative to patient access to clinical effectiveness, to us assuring that all of our patients in our communities get what they need. I'm not talking about an APP only strategy. I'm talking about a full team that includes physicians, APPs, nurses, MAs, pharmacists, you're going to hear more from us this year on pharmacists and dieticians and social workers. And I mean, I also feel strongly that our teams need to be continued to broaden because there's a lots of other skills and competencies that our patients deserve to have access to. Ari, any questions pop in? I think you got it all covered. Well, I'll take that as a win. So you all enjoy the rest of your day. Thank you so much. And we'll be sending out the next year survey probably sometime around September.

advanced practice providers

cardiovascular care

APPs

RVUs

APP compensation

scheduling models

APP leadership

team-based care

MedAxiom platform