Onboarding the APP: Case Exposure, Educational Resources, and Provider Collaboration

Adrianne Maurer

Hi, Katie. I thought we could talk a bit more about chronic GVHD, but more from the provider's standpoint. As you know, this is a unique space in which we work, so there's a lot that goes into becoming an expert in this field. Do you find it challenging to bring new APPs into this role?

Katie Sellers

I'm glad that we can have a conversation about onboarding the APP into the chronic GVHD space. It can be challenging because this is such a niche, specialty practice. It takes a multifaceted approach to appropriately onboard the APP.

We know that a thorough onboarding process can help APPs feel more comfortable and improve our productivity, job satisfaction, and retention. It also helps organizations achieve their goals by having committed, well-developed APPs. So, translating that into the chronic GVHD space is incredibly important considering the complexity and unique nature of our field.

The more case exposure to chronic GVHD patients that the APP has, the better prepared the APP will be to manage these patients. However, you must start with the basics rather than diving in. Square one is making sure the APP has a comprehensive orientation and that they're accustomed to the clinic. From there, we can take a deep dive into the education space and make sure the APP has components of didactic learning as well as physician and senior APP mentorship.

While this whole process can be challenging, taking a stepwise approach and finding education from different sources throughout the onboarding process can help ensure the APP is well-trained and equipped to integrate into the chronic GVHD space.

Adrianne Maurer

I echo those sentiments. I’m onboarding a new APP as we speak, and one thing I find really challenging is applying some of that didactic learning to a patient scenario. One thing I have struggled with for a long time is how to coach and mentor new APPs on identifying and managing sclerotic skin GVHD.

In my experience, it's one of those conditions that you have to see multiple times before you truly get a good understanding of it. I'm curious how you navigate that complexity. And even beyond skin GVHD, there are a lot of other subtleties with chronic GVHD. So, I'm interested in how else we might be able to support a new APP.

Katie Sellers

I like to start from the patient perspective, looking at resources available for patients, as it brings it to a basic level of understanding, and how we may hear signs or symptoms from the patients themselves. Working to develop patient-centered language and guiding questions may help the new APP recognize and identify chronic GHVD. For the challenging manifestation of sclerotic features, asking patients if they have difficulty reaching above their heads or behind their backs, difficulty buttoning their blouse, or an inability to open their mouth fully, is a place to start. And then we supplement with a thorough exam. It is essential for the new APP to develop a systematic, head-to-toe assessment of the GVHD patient. Repetition is key and seeing consistent patients as well as unique cases will help the APP develop their approach to the chronic GVHD patient.

We can aid in developing this systematic approach through collaboration with experienced APPs and physician partners. I also like pulling new APPs into visits when there is a less commonly seen, unique manifestation. Ensuring the APP is exposed to as many cases as possible during their onboarding is essential so they can develop their language and examination approach and be exposed to both clear and unique manifestations. Ultimately, this will lead to picking up on subtleties as the APP becomes more comfortable with the patient population.

Adrianne Maurer

It does. That's something we have our new APP doing right now, establishing with a couple of patients and following them in succession. And that's not just from a "Can I identify GVHD?" standpoint, it's also from a practical standpoint. Can they get through this full visit and document it, know what the next steps are, and learn to do that all quickly so when they see a new patient on their own they have the resources to be successful?

Katie Sellers

I totally agree with you, Adrianne. Consistent exposure to a specific patient cohort and developing a common language is so important.

We have new APPs watch videos and attend lectures which is helpful, but there’s so much learning to gain by sitting in the exam room with the patient. There are ample tools and tricks to help us orient those APPs quickly into practice.

One tool that’s particularly helpful is ASTCT’s Advanced Practice Provider Onboarding and Resource Guide.¹ It is a comprehensive guide starting with routine lab management and infectious complications and delves into the system-based manifestation of graft-vs.-host disease. It also provides links to articles and videos. It is an extensive checklist that may be overwhelming but can be parsed out to useful sections for the APP, notably in GVHD. It is a starting point. I want to recognize the importance of dedicated education time integrated into onboarding and not leave the training explicitly to just the clinic practitioners. There have been tons of investment, time, and research put into these onboarding guides and using them is key to success for the new APP.

Adrianne Maurer

That's great. I very briefly peeked at that guide a couple of months ago and was overwhelmed with how much information there was, but I think you made a really excellent point. It's a jumping off point, right? You don’t have to check off everything on this list. It's a place to start. And the benefit to this is that you can tailor it to what that specific APP needs and what fits within your organization.

Katie Sellers

Absolutely.

Adrianne Maurer

There’s one other thing that I want to make sure we touch on. In previous conversations, we've talked about how our centers are well prepared to manage patients with chronic GVHD, but what about those community practice folks who aren't well-versed in how to identify and manage chronic GVHD? I wonder if you have any pearls for educating community providers who may feel a little bit scared or intimidated by chronic GVHD?

Katie Sellers

Sure. The National Marrow Donor Program has fantastic education available on their website for incorporating the patient back into a community-based practice.² This covers routine lab monitoring, and a staging timeline, as well as education to assist in identifying graft-vs.-host disease. The community oncology APP may not be comfortable managing those patients, but it may prompt them to reach out to their transplanting team when they identify GVHD and collaborate on a treatment plan for the chronic GVHD patient.

Your center, Fred Hutch, has a resource with 10 GVHD screening questions for allogeneic stem cell transplant patients.³ Any new APP or community practice provider can use this list to try to grasp not only the most basic manifestations, but also some of the more fine-tuned manifestations of GVHD, and prompt them to collaborate with the transplanting center.

Adrianne Maurer

Right. Once the APP identifies those little concerning areas, the next step is knowing your resources. Knowing who your contact is at those transplant centers makes a huge difference. And from the perspective of somebody who works at a transplant center, our job here is outreach, to make sure that our contact information is out there for those community providers who may need it.

Katie Sellers

Anytime I'm referring a patient back to a community center, I always make sure that the practice has my contact information so they can reach out at any time. We want to make sure that the collaborating team feels comfortable with the patient case and take time to review and relay to the provider any of the nuances that aren't captured in our documentation.

Being able to have a conversation about a patient is also key. I had a patient who needed to transfer to a different center within town because of insurance restrictions. In a brief phone conversation with the physician that was taking on the patient case, we were able to capture a lot of the intricacies of the patient case. We touch base every once in a while via email or over the phone, and it helps us to work toward the best outcome for the patient.

Adrianne Maurer

And that's what this is all about, right? Making sure that we optimize the outcome for the patient.

Katie Sellers

It is.

Adrianne Maurer

Is there anything else you wanted to mention about onboarding new APPs?

Katie Sellers

Yes, one last plug. I can’t stress enough how important it is to attend clinical conferences. It could be a clinical case conference at your center, going through complex chronic GVHD cases. Conferences like APSHO’s JADPRO Live and ASTCT’s Tandem Meetings or Clinical Education Conference, specifically the APP-focused tracks, can be hugely impactful because of not only their education platforms but also the opportunities for networking and meeting peers and colleagues who are managing cGVHD across the country.

Adrianne Maurer

The APSHO website is very helpful as well. They have so much education, networking opportunities, and forums just within the APSHO community itself. It has its own GVHD page where there are lots of experts like you providing information. It all goes back to knowing your resources, right?

Katie Sellers

Absolutely. We're fortunate that organizations like APSHO and ASTCT have put out guidelines and resources for everybody to use, whether you're new to practicing, you're continuing practice, or you're trying to onboard a new APP. This can be an intimidating space, so making sure we have all these resources available to everyone is important. I have to call out Fred Hutch because your long-term follow-up guidelines are fantastic.⁴

Adrianne Maurer

They are saints, let me tell you. They really do prepare APPs. And I think it's because we transplant patients all along the Western seaboard. Staff there have dedicated countless hours and manpower to having those guidelines readily available for community providers. And again, they're fully staffed with nurses and APPs as well for consults as needed.

Katie Sellers

Coming from a large transplant program, but a community-based practice, we are thankful for centers like yours that are putting forth resources to help our referring centers and collaborating practitioners. So, thank you to the Hutch for creating resources that we can all use and translate into our practices.

Adrianne Maurer

Well, thank you Katie. I’m glad we were able to have this conversation about onboarding new APPs and supporting our community providers. I look forward to future conversations about more topics, GVHD-related and all.

Katie Sellers

I enjoyed talking about this with you, Adrianne.