The care of patients with rheumatic diseases requires physicians and health professionals with the experience and knowledge of complex rheumatic diseases. The collaboration of physicians, nurse practitioners, physician assistants, social workers, cognitive behavioral therapists, physical therapists, and others allows for the optimum outcomes for our patients. This month the ACR and the ARHP presidents are collaborating to describe the members of the rheumatology practice team and the roles they fill in the care of patients with rheumatic disease.
Team Rheumatology
In rheumatology, there is no such thing as a Lone Ranger. Because rheumatic diseases are often complex and affect many aspects of the patient’s life, effective management requires the coordinated efforts of a diverse group of professionals. Wikipedia defines a team as a group linked in a common purpose, and notes that a team is especially appropriate for conducting tasks that are high in complexity and have independent subtasks. This definition certainly describes the rheumatology practice team, composed of several health and office professionals who work together to serve the patient’s needs. To better understand what each professional brings to the team, we would like to share the clinical rheumatology team responsibilities and why each team member enjoys rheumatology care.
The opportunity to be a patient’s doctor for an extended period of time, along with the challenges of diagnosis and the rapid development of new effective therapies, makes Dr. Borenstein happy being a rheumatologist—he would not do anything else. The rheumatologist’s role on the practice team is that of the organizer of the team that treats the patient with rheumatic disease. You never know what challenge you will see, and Dr. Borenstein likes rheumatology because of the variety of problems that await him on the other side of the examination room door. Every patient is different, even though they all have a rheumatic disease, and the selection of the ideal team for a patient is based upon their illness and the social environment necessary to offer a comprehensive program of care. As a rheumatologist, you also do not know if that patient will be with you for one visit or for decades. As team leader, the rheumatologist receives information from the other members of the team and modifies the plan to offer the best outcome for the patient.
Nurse Practitioners and Physician Assistants
To help meet the demands of an increasing patient load, rheumatology practice teams have added nurse practitioners (NPs) and physician assistants (PAs). The NP and PA evaluate patients by performing a comprehensive history and physical examination, order and interpret appropriate diagnostic tests—such as laboratory studies, X-rays, magnetic resonance images, and musculoskeletal ultrasounds—formulate a plan to manage the patient’s condition, and prescribe, order, and implement interventions and treatments in accordance with state law. They also evaluate and document patient and family progress toward attainment of expected outcomes and provide consultation to other providers to optimize the plan of care and affect system change.
A typical day for Susan Richmond, MS, PA-C, at the Rheumatology and Autoimmune Disorder Medical Group in Raynham, Mass., will include a variety of patient visits, 10 to 15 total, including initial visits, follow-up appointments, and patients needing urgent attention. She may also see patients having an infusion or manage a patient in the event of an adverse reaction. Richmond also collaborates on difficult or unusual cases with her supervising rheumatologist.
As a pediatric NP at Nationwide Children’s Hospital in Columbus, Ohio, Karla Jones, MS, RN, CPNP, states that accurately diagnosing and treating rheumatic diseases can be challenging, but she enjoys the intellectual stimulation that it entails. She also enjoys working as a team and knowing that everyone involved has the goal of helping children and their families meet the child’s physical, social, and emotional needs.
Registered Nurses
Registered nurses (RNs) have a long and important history in rheumatology practice. They assess each patient’s health status, response to treatment, function in relation to activities of daily living, and ability to provide self-care and cope with chronic illness. Collaborating with the patient, family, rheumatologist, and other health professionals, the RN implements a variety of interventions that are designed to manage pain, improve function, maximize independence, provide education, strengthen coping strategies, and improve access to community resources. In addition, the RN administers, monitors, and educates about medications.
Lisa Robbins, RN, provides education to patients and families regarding medications and injection techniques, diagnosis, plan of care, and support activities at Hershey Medical Center in Hershey, Pa. She also handles patient calls about illness, medications, symptoms, school issues, education, and support, and helps the rheumatologist stay on schedule by starting history and physicals with patients in the exam room when not engaged with the education of patients or taking calls.
Many rheumatology practices now conduct clinical trials. For Tara Barker, RN, BSN, MSN, who serves as a clinical research nurse coordinator at the Cleveland Clinic, has responsibilities that relate to patients who participate in rheumatoid arthritis, osteoarthritis, scleroderma, and fibromyalgia clinical trials. In this role she ensures that the patient understands the consent forms for study participation and provides information to help with their decision. Once they have agreed to participate, she makes sure that the research protocol is followed by scheduling assessments, infusions, and medication dispensing for the patients and supports and assists patients in coping with their specific chronic illness or disease. Additionally, she works with the trial sponsors to make sure the trial runs with integrity and compliance.
When asked what she likes most about her rheumatology nursing responsibilities at the Children’s Hospital of Los Angeles, Sandra Watcher, RN, states, “I like the collaboration with the multidisciplinary team, patients, and families. Taking complex diseases and making information understandable to patients and families. Helping them learn to live with chronic illness and increase their understanding, normalizing, and living with chronic illness.”
Accurately diagnosing and treating rheumatic diseases can be challenging, but knowing we have an experienced team of rheumatology health and office professionals means the challenge will be met.
Other Team Members
Three other health professionals utilized in a rheumatology practice are the licensed practical nurse, licensed vocational nurse, and medical assistant. The licensed practical nurse and licensed vocational nurse handle phone triage, insurance authorizations for medications, and medication education. Lisa Emig, LPN, at Wellspan Health, enjoys the responsibility of questioning patients about their symptoms, assessing their condition for possible cause of pain, and helping them mange the pain. She states, “having a patient call me back in a week to tell me they feel so much better brings so much satisfaction to my work.” The medical assistant is generally the first team member a patient encounters in a practice setting because they take the patient to the exam room, take vital signs, and review the medication list with the patient.
Another very important part of the rheumatology team is the practice manager and his or her staff. The practice manager oversees all business activities, including budget monitoring, account receivables and payables, banking, insurance, medication and medical supply purchasing, regulatory compliance, facilities, computers, human resources, staffing, training, office staff supervision, and patient relations. The practice manager may discuss staffing, scheduling, insurance issues, or a new administrative implementation like electronic prescriptions or electronic health records with the rheumatologist, NP, or PA. The practice manager’s interaction with the nursing and medical assistant staff relates to insuring that they comply with appropriate work documentation and have the tools necessary to treat their patients. However, a primary interaction for a practice manager is overseeing the front desk and billing staff, where many of the practice problems can arise.
Linda Merritt, RMM, at Arthritis Specialists Group in Utica, N.Y., states, “I work personally with patients that are in need of financial assistance to obtain their prescribed medications, as rheumatology care can become quite costly for patients and the application process for this benefit can be burdensome. If I can help them navigate the system and obtain their medications at a cost they can afford, then I take the time to do so.” Because a practice manager must know something about all aspects to running a medical business, they wear a lot of hats in rheumatology practice. Merritt’s daily challenge and satisfaction is keeping those hats balanced so patients leave the office feeling good about the care and service they received.
Team Beyond the Office
There are health professionals who may not work in a rheumatology practice but are essential to the overall care of the rheumatic patient. The rheumatology practice may refer the patient to these disciplines to assist with rehabilitation, coping, depression, and access to community resources and services. The physical therapist assesses and evaluates the patient, develops an individualized plan of care, provides patient education, and performs specific therapeutic interventions. Therapeutic exercises are used to improve a patient’s muscle strength, joint mobility, and cardiovascular and pulmonary function.
An occupational therapist (OT) assesses and evaluates the patient, develops an individualized treatment plan, and educates patients and their families to adapt environments, modify tasks, and use equipment to promote independent function and help gain, or maintain, full participation in self-care, daily home tasks, work or school, and leisure or play. The OT teaches principals of energy conservation, joint protection, and stress management to minimize fatigue, reduce pain, and improve safe performance in daily activities.
A clinical psychologist assesses the individual’s and family’s psychological status and ability to cope with the patient’s disease. Based on evaluation, the clinical psychologist tailors a treatment plan to meet the needs of the patient for a short or long-term treatment. A psychosocial assessment provides the basis for the social worker’s intervention. The assessment includes evaluation of the patient’s resources, strengths, and support systems. A social worker can guide the patient in more effectively negotiating the health care system, maximizing personal and social resources in dealing with the acute and long-term issues on managing a chronic disease, and identifying community resources that assist the patient in returning to functional independence.
As you can see, it takes all kinds of professionals to successfully treat patients with rheumatic disease. Their responsibilities are varied, but each plays an integral role in the overall patient care. As stated earlier by Jones, accurately diagnosing and treating rheumatic diseases can be challenging, but knowing we have an experienced team of rheumatology health and office professionals means the challenge will be met. the rheumatologist
Dr. Borenstein is clinical professor of medicine in the division of rheumatology at George Washington University Medical Center, in Washington, D.C., and in private practice at Arthritis and Rheumatism Associates there. Contact him via e-mail at [email protected]. Dr. James is president of the ARHP. Contact her at [email protected].
