Mid-level practitioner

Mid-level practitioners, also called assistant practice clinicians, are health care providers who have received different training and have a more restricted scope of practice than physicians and other health professionals in some states, but who do have a formal certificate and accreditation through the licensing bodies in their jurisdictions.[1] Advanced Practice Provider (APP) is a term which Nurse Practitioners, Nurse Anesthetists, Physician Assistants, Clinical Nurse Specialists, and Nurse Midwives often prefer for themselves rather than"Mid-level provider".[2] The terms "Mid-level provider" or "Mid-level practitioners" have been widely accepted for many years however and are commonly used by most physicians as well as by the Federal Government of the United States.[3][4] Many providers simply prefer their professional title, such as nurse practitioner (NP) or physician assistant (PA).


Because of their diverse histories, a multitude of mid-level health worker categories can be found in different countries under different titles. Their training, functions, scope of practice, regulation, and integration into the formal health system vary from country to country. Mid-level practitioners have many different titles, e.g. physician assistant, clinical officer, or nurse practitioner. They are increasingly being used to render services autonomously, particularly in rural and remote areas, to make up for physician shortages.[5]

MLPs by country

South Africa

In 2008, a new mid-level practitioner role was introduced in South Africa, known as clinical associates. The role was intended to support the district hospital workforce.[6]

United Kingdom

Mid-level practitioners in the UK are known as 'Advanced Clinical Practitioners' (ACP) and is an evolution of many differing professions which use various titles such as ‘Extended Scope Practitioner’ or ‘Advanced Practitioner’. Historically there has been debate over the consistency of quality in these senior clinicians and therefore it became necessary to generate a distinguished definition of the ACP role. The ACP:

  • Is a registered healthcare practitioner with a minimum of 5 years clinical experience (2 years in a senior clinical role)
  • Has acquired expert knowledge and complex decision making skills which may be an extension of their traditional scope of practice
  • Will undertake a two-year level 7 (Master’s degree) training course in Advanced Practice
  • Will maintain training and CPD requirements [7]

This is an emerging role and is showing a good deal of promise in meeting the demands of the UK's rapidly evolving healthcare requirements. ACPs may practice in the acute setting (ED, critical care, medical or surgical wards) or community General Practice / family medicine. The majority can independently assess, investigate (through blood science / imaging / labs etc), diagnose and formulate a treatment including prescribing medications or referring to specialist care.

The deployment of ACPs is considered to be part of a Value Based Recruitment framework driven by Health Education England (HEE). This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care.[8]

United States

In the United States, mid-level practitioner is a term used to describe the category of health care workers with training less than that of a physician but greater than that of more ordinary nurses and other medical assistants. In recent years some organizations and specialties have proposed the discontinuance of the term mid level in reference to professional practitioners who are not physicians.[9][10][11][12] This shift follows a change in paradigm toward a collaborative team based care model.[13][14] Other groups such as the American Academy of Family Physicians considers the term to be appropriate as it delineates a clear distinction between the training and expertise of physicians and non-physicians, and considers the term "providers" that encompasses both physicians and non-physicians to be derogatory.[15]

The term mid-level practitioner or mid-level provider related to the occupational closure of healthcare. This concept centered around physicians as the ultimate professional responsible for healthcare. As healthcare demands have increased in the United States due to an aging population, a physician shortage and the implementation of the Patient Protection and Affordable Care Act of 2010 there has been a shift toward more independence in practice for professionals such as advanced practice nurses, pharmacists, dentists, podiatrists, dental therapists and physician assistants who were previously described as part of this category.[16]

As an example of a shift away from the US Medicare system terms both advanced practice nurses and physician assistants as "non-physician practitioner" (NPP).[17] Medicare will pay for emergency department services when these services meet the critical care services definition and requirements.[18]

Controversy

The American Academy of Nurse Practitioners (AANP) released a position statement in 2009, updated in 2010, 2013 and 2015 denouncing the use of several relegating terminology. Terms such as "mid-level provider," "physician extender," "limited license provider," "non-physician provider," and "allied health provider" when referring to nurse practitioners are considered derogatory by the AANP.[19] The American Academy of Nurse Practitioners prefers that nurse practitioners are referred to as "Nurse Practitioners," "independently licensed providers," "primary-care providers," "health-care professionals," and "clinicians." in reference to the legal and professional paradigm that nursing practice is considered separate and independent of other licensed professionals.[20]

Drug Enforcement Administration

The term mid-level practitioner as found in the DEA classification in Section 1300.01(b28), Title 21, of the Code of Federal Regulations is not a health care designation and must not be confused with the term as it is defined above. The DEA uses the term mid-level as a means of organizing its drug diversion activities. The term mid-level practitioner as used by the DEA Office of Diversion Control include clinicians, other than a physician, dentist, veterinarian, or podiatrist, who are licensed, registered, or otherwise permitted to dispense a controlled substance in the course of professional practice.[21][22] Some health professionals considered mid-level practitioners by the United States DEA solely for the purposes of drug diversion control include:

See also

References

  1. ↑ Lehmann, U (2008), Mid-level health workers: The state of the evidence on programmes, activities, costs and impact on health outcomes - A literature review (PDF), Geneva: World Health Organisation
  2. ↑ Bishop CS (2012). "Advanced practitioners are not mid-level providers". J Adv Pract Oncol. 3 (5): 287–8. PMC 4093350. PMID 25031957.
  3. ↑ http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf, Medicare Carriers Manual by the Centers for Medicare and Medicaid Services (CMS) pursuant to Transmittal 1548, 2008, Accessed 11 June 2011
  4. ↑ http://epmonthly.com/article/mid-level-providers-who-they-are-what-they-do-and-why-they-re-changing-emergency-medicine/%5Bfull+citation+needed%5D
  5. ↑ Mid-level health providers: a promising resource to achieve the health Millennium Development Goals (PDF), Geneva: World Health Organization, Global Health Workforce Alliance, 2010
  6. ↑ Doherty, J; Conco, D; Couper, I; Fonn, S (2013). "Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates". Global Health Action. 6: 19282. doi:10.3402/gha.v6i0.19282. PMC 3556716. PMID 23364079.
  7. ↑ https://hee.nhs.uk/sites/default/files/documents/East%20Midlands%20Advanced%20Clinical%20Practice%20Framework.pdf%5Bfull+citation+needed%5D
  8. ↑ https://hee.nhs.uk/sites/default/files/documents/ACP%20Framework%20for%20the%20WM.PDF%5Bfull+citation+needed%5D
  9. ↑ Use of Terms Such as Mid-Level Provider and Physician Extender (PDF), American Academy of Nurse Practitioners, 2015, retrieved 10 April 2016
  10. ↑ Use of Terms Such as Mid-Level Provider and Physician Extender (PDF), Emergency Nurses Association, 2011, retrieved 14 April 2016
  11. ↑ Don't Call PAs Midlevel Providers, Physician Practice Periodical, 2014, retrieved 14 April 2016
  12. ↑ Stop calling nurse practitioners mid-level providers, MedPage Today's KevinMD, 2014, retrieved 14 April 2016
  13. ↑ A Team-Based Approach to Primary Care, University of California San Fransicisco, 2014, retrieved 14 April 2016
  14. ↑ Core Principles & Values of Effective Team-Based Health Care (PDF), National Institute of Medicine of the National Academies of Science, 2012, retrieved 14 April 2016
  15. ↑ http://www.aafp.org/about/policies/all/provider-term-position.html%5Bfull+citation+needed%5D
  16. ↑ Mid-Level Providers in a Changing Healthcare Workforce, Becker's Hospital Review, 2010, retrieved 14 April 2016
  17. ↑ http://www.cms.hhs.gov/transmittals/downloads/R1776B3.pdf, Medicare Carriers Manual by the Centers for Medicare and Medicaid Services (CMS) pursuant to Transmittal 1776, implemented on October 25, 2002, Accessed 11 June 2011
  18. ↑ http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf, Medicare Carriers Manual by the Centers for Medicare and Medicaid Services (CMS) pursuant to Transmittal 1548, 2008, Accessed 11 June 2011
  19. ↑ Use of Terms Such as Mid-Level Provider and Physician Extender (PDF), American Academy of Nurse Practitioners, 2015, retrieved 10 April 2016
  20. ↑ Devi, Sharmila (2011). "US nurse practitioners push for more responsibilities". The Lancet. 377 (9766): 625–626. doi:10.1016/S0140-6736(11)60214-6.
  21. ↑ http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html, U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control, Mid-Level Practitioners Authorization by State, Accessed 11 June 2011.
  22. ↑ http://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf, U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control, Mid-Level Practitioners Authorization by StateChart, Accessed 11 June 2011.
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