How to Improve Onboarding of Advanced Practice Providers

Sentara Health has implemented an intensive onboarding program for new primary care advanced practice providers, with an emphasis on the first year of employment.

Sentara Health is expanding its advanced practice provider workforce in primary care, and the health system has implemented a robust onboarding program for these APPs.

In primary care, about 40% of Sentara Health's clinician workforce consists of APPs. The health system is planning to increase that number, and they may surpass the number of physicians.

Sentara Health launched an intensive onboarding program for new primary care APPs in July 2024. Retention was a top goal of the program, according to Stephanie Zeiber, MPA, PA-C, the health system’s director of advanced practice provider development.

"Primarily, we decided to have this onboarding program due to the rapidly expanding APP workforce as well as the significant time and cost required to replace APPs when they leave," Zeiber says. "High turnover also disrupts patient trust."

The varying training backgrounds of APPs was another impetus for adopting the new onboarding program.

"We wanted to adopt an onboarding program that would enable these individuals to receive a standardized approach to acclimating to the organization," Zeiber says. "We offer this onboarding program to all of our new primary care APPs, whether they are a new graduate or an APP who is coming into primary care from another specialty."

The onboarding program is generating positive results. So far, 50 APPs have gone through the program, with a 98% retention rate. Early data also shows improvements in measures such as productivity, electronic medical record efficiency, and APP engagement scores.

Stephanie Zeiber, MPA, PA-C, is director of advanced practice provider development at Sentara Health. Photo courtesy of Sentara Health.

How the Program Works

There are five elements of the primary care APP onboarding program.

The curriculum component is the most extensive part of the program. This includes six months of didactic curriculum focused on clinical refresher courses and professional development training. Most of the curriculum is asynchronous, with training conducted through an internal learning platform, and APPs are assigned to complete training modules on a weekly basis. APPs are given dedicated time during the week to complete the training modules.

The curriculum includes training and support for using the health system's EMR, which enables APPs to learn efficiency skills. APPs also receive training on coding.

Second, about 75% of new primary care APPs are paired with a mentor. Program participants are usually mentored by an APP who has at least three years of experience. Mentors are nominated by a member of their clinical leadership team such as a medical director.

Mentors are paid for mentoring at an hourly rate. Most mentors work with new APPs about one hour per week.

Third, new primary care APPs participate in shadowing of other clinicians. They spend time with other primary care providers at their practice and also shadow specialists, particularly those who have the biggest challenges for patient access such as cardiologists.

Fourth, new primary care APPs receive evaluations at the six-month and 12-month marks of their employment. The evaluations are comprehensive and based on the professional domains and competencies outlined for physician assistants and nurse practitioners. The evaluations are conducted by an APP's collaborating physician, with mentors also providing insights.

Fifth, there is a ramp-up schedule for new primary care APPs that covers the first six months of practice, with flexibility in the schedule based on an APP's needs. For the following six months, the goal is to continue to ramp up an APP's schedule and get them more comfortable with their permanent schedule.

The onboarding program continues into the second and third years of a primary care APP's employment, according to Zeiber.

"In the second year, these tracks mainly focus on professional development, with topics such as value-based care, population health, quality improvement, and goal setting," Zeiber says. "In the third year, we will be providing APPs with more advanced opportunities such as becoming mentors or serving on committees."