Rheumatology Workforce for the 21st Century

The roles of advanced practice providers, social workers & physical therapists

WASHINGTON, D.C.—The effective management of patients with rheumatic diseases requires a multi-disciplinary, team-based approach that draws on the expertise of a range of healthcare professionals addressing the often-complex issues surrounding systemic and autoimmune conditions. Advanced practice providers, physical therapists (PTs) and social workers all play an important role in this team-based approach, each bringing unique expertise to ensuring optimal care is delivered to and acted on by the patient.

In a session on the state of interprofessional care in rheumatology, speakers described the current and potential roles of advanced practice providers, PTs and social workers in the care of patients with rheumatic illnesses. Patient education stood out as a key way for all three of these professional groups to contribute to the care of patients with rheumatic conditions, albeit with different hues that augment the role of rheumatologists.

Advanced practice providers ranked patient education as their top responsibility, followed by medication dose adjustments and conducting physical exams. For PTs, patient education is an essential component of helping patients with pain and functional limitations around their disease. For social workers, patient education is critically linked to understanding holistically all the factors that guide and may undermine a patient’s ability or willingness to engage in treatment and receive optimal care.

The session brought into sharper focus the needs of patients with rheumatic diseases that require a team-based approach, including the incorporation of more advanced practice providers as the rheumatology workforce shrinks, the inclusion of PTs to support and improve daily functioning and the reliance on social workers as the linchpin that holds the team together by ensuring, for example, that a proposed treatment can actually be delivered to and adhered to by a patient given the social determinants of health that govern their life.

Key Takeaways

1. The number of APPs is growing, & their role is expanding.

Leila Khalili

The role of advanced practice providers, mainly nurse practitioners (NPs) and physician assistants (PAs), continues to grow in rheumatology. Leila Khalili, NP-C, director of research operations, Lupus Center, Columbia University Irving Medical Cancer Center, New York, highlighted data from the 2015 adult rheumatology workforce study showing that the numbers of NPs and PAs are projected to increase by 40.4% and 45.3%, respectively, by 2030; meanwhile the number of adult rheumatologists is projected to decrease by 30.9%.¹

More recent data show an increase of 141% for advanced practice providers between 2009 and 2020, and a 23% increase in the number of clinically active rheumatologists.² The data also show that the number of clinically active rheumatology providers grew by more than 20% over the past decade—to a high of 6,036 in 2020. However, that growth appears to be flattening.

Ms. Khalili cited the cost of medical school, medical practice mergers, the rising value of team-based care and task shifting as contributing factors to why the number of advanced practice providers is growing faster than the number of rheumatologists.

Most, if not all, advanced practice providers see patients for routine or urgent follow-up care and are primarily responsible for patient education, adjusting medication doses and conducting physical exams, with a high percentage (70%) also performing new patient evaluations.

Other responsibilities of advanced practice providers, as a part of a team-based approach, include joint injections, baseline ultrasound evaluations, referring patients to triage, infusion management, practice management and advocacy.

2. Integration of PTs is slow & low; innovations are needed.

Daniel White

Daniel K. White, associate professor in the Department of Physical Therapy at the University of Delaware, Newark, spoke about the role of PTs and said their work in helping patients to reduce pain and functional limitations is ideal for patients with chronic illness, such as rheumatic diseases. He said a referral to a PT can also offer patients additional education on understanding their limitations and how to work around those limitations.

However, he called current referral to PTs slow and low, citing a study showing that only 5% of primary visits for knee osteoarthritis result in a referral to a PT.³ Although rheumatology is currently not a separate subspecialty within PT, he said initiatives are underway to improve PTs in rheumatology care. To date, most patients with rheumatic diseases referred to PT are seen in an outpatient orthopedic clinic.

He urged rheumatology practices to refer patients to a PT and suggested using Google Maps to easily find them. Good candidates for PT include patients with impairments in pain, decreased range of motion or weakness, as well as those with such functional limitations as difficulty walking or climbing stairs and who are unable to participate in an enjoyed activity, such as being a parent or grandparent. Mr. White said a good indicator for a referral is when a patient talks about wanting to do something, (e.g., golf). A PT can help that patient meet his or her goal.

Mr. White underscored that a referral to a PT is not just for patients with major functional limitations. It’s also appropriate for patients who just want to manage their disease better from a physical standpoint.

He emphasized the need for innovations in the field, citing telehealth as one increasing tool that allows for easier access to patients in rural areas or when transportation is difficult, as well as integrated care in which a PT is part of a multidisciplinary team. For a model of the latter, he referred to a 2016 study illustrating a flow chart of integrating a PT in rheumatology care.⁴

3. Social workers are the linchpin of integrated care.

Jillian Rose-Smith

Jillian Rose-Smith, PhD, MPH, LCSW, vice president and chief health equity officer at Hospital for the Hospital for Special Surgery, New York, made a compelling case for the need for a social worker for all patients with rheumatic diseases beginning at the time of a diagnosis. Emphasizing the importance of a multidisciplinary approach to rheumatology care advocated by both the ACR and EULAR, she cited the many roles social workers play in bridging the gaps in care that are critical to ensure an optimal delivery of care by addressing the physical, social, emotional and spiritual needs of a patient. She noted the need to ask patients the right questions, and not just make assumptions based on eyeballing a patient.

Example: A woman was prescribed a biologic that was shipped to her home in Manhattan, but follow-up lab work indicated that that patient wasn’t taking the biologic. The woman worked and always came to her clinical appointments dressed like a corporate executive. Through a social worker assessment, it turned out the woman had lost her housing, was couch surfing and did not have access to the biologic. An easy solution: The social worker had the biologic sent to the hospital for the woman to receive the treatment. Ms. Rose-Smith emphasized that by simply asking the right questions and identifying problems, easy solutions are often available that help patients and reduce waste in the healthcare system.

Ms. Rose-Smith made a strong argument for including a social worker in a team-based approach to rheumatic care, emphasizing that optimal care requires a deep understanding of what is important to a patient and the factors that may impede delivery of and adherence to treatment.

Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.

References

1. Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.
2. Mannion ML, Xie F, FitzGerald JD, et al. Changes in the workforce characteristics of providers who care for adult patients with rheumatic and musculoskeletal disease in the United States. Arthritis Rheumatol. 2024 Jul;76(7):1153–1161.
3. Khoja SS, Almeida GJ, Freburger JK. Recommendation rates for physical therapy, lifestyle counseling, and pain medications for managing knee osteoarthritis in ambulatory care settings: a cross-sectional analysis of the National Ambulatory Care Survey (2007–2015). Arthritis Care Res (Hoboken). 2020 Feb;72(2):184–192.
4. Vare P, Nikiphorou E, Sokka T, et al. Delivering a one-stop, integrated, and patient-centered service for patients with rheumatic diseases. SAGE Open Med. 2016 Jun 14:4:2050312116654404.