SPECIALTY SPOTLIGHT: ADULT-GERONTOLOGY PRIMARY CARE

If there is a nurse practitioner (NP) specialty often misunderstood, it is Adult-Gerontology Primary Care (AGPC).

“A lot of people believe we only take care of geriatric patients, because of the specialty’s name. The name is really a recognition so we don’t forget the need to care for the growing population of older patients, but our population focus is people 13 years old and up,” says Christine Colella, DNP, APRN-CNP, FAANP, professor, AGPCNP programs director and interim associate dean and executive director for graduate programs. Colella also works as a primary care NP at Lincoln Heights, a federally qualified health center in Cincinnati, Ohio.

For years, adult health NPs and gerontological NPs were educated and certified separately. In 2008, when education regulations specified six population foci for advanced-practice nursing, the two paths merged as adult-gerontology. The scope of practice for adult-gerontology NPs can be either primary care, a community-based specialty that focuses on illness prevention, health promotion and management of chronic health conditions, or acute care, an inpatient/hospital-based specialty that focuses on treating illnesses.

“Because I worked as a registered nurse in a hospital, my initial choice for my graduate degree was the acute care program. When I learned more about adult primary care, I switched programs because I wanted to be community-based,” says Kim Mullins, DNP, APRN-BC, AOCNP, associate professor and AGPCNP online program coordinator. Mullins also works as an NP at Oncology Hematology Care (OHC) in Cincinnati.

“Through my NP career, I worked in neurology and GI (gastrointestinal) research and have worked for 16 years in an outpatient setting treating radiation/oncology patients. I do see some patients in the hospital for consultations, but I don’t manage their care in the hospital,” Mullins says.

AGPCNPs work in community-based settings assessing, diagnosing, prescribing medications, ordering and evaluating labs and referring patients to specialists when needed. They consider the environmental, occupational, social and economic background of patients and can work in a wide range of areas, such as primary care, dermatology, cardiology, endocrinology, neurology and many more. Some of these areas require additional certification through specific boards.

“Although I’m taking care of patients with cancer, I couldn’t do my job without the primary care background. So much of what I do is grounded in primary care,” Mullins says. “When they get to me, I’m not just treating their cancer, I’m treating the whole person, which may include helping manage other comorbidities.”

While AGPCNPs enjoy a high level of autonomy and independence, they also bear a lot of responsibility.

“We do a lot of what physicians do and, although I need to have a collaborating physician, I make my decisions independently. It’s an incredible amount of accountability and responsibility,” Colella says. “If you went to an urgent care or the emergency department tomorrow, the last sentence you would hear before you left is, ‘Follow up with your primary care provider.’ That’s me. We’re the ones that manage them after they’ve had the acute episode.”

Despite the fact that the number of Americans ages 65 and older is projected to nearly double from 52 million in 2018 to 95 million by 2060, and the 65-and-older age group’s share of the total population will rise from 16% to 23%, only about 7% of the advanced practice registered nurse (APRN) workforce is certified in AGPC, according to the 2020 American Association of Nurse Practitioners’ National Nurse Practitioner Sample Survey.

“A lot of nurses hear that becoming an FNP (Family Nurse Practitioner) makes them more marketable. This perception has been driven by retail clinics, but the reality is that if you have no interest in working with a population under 13 years old, AGPCNP is the right specialty for you,” Mullins says. “AGPCNP students have higher exposure to adult and women’s health care during their clinicals than FNP students do, since they don’t need to complete clinicals in pediatrics.”

To get a deeper understanding on the breadth of AGPCNP opportunities, we heard from four UC alumnae about their journey before and after becoming AGPCNPs: Heather Welch (HW), who earned her Doctor of Nursing Practice (DNP) in 2018; Lynn Mellencamp (LM), who earned her Master of Science in Nursing (MSN) in 2009; Lisa Gebhart (LG), who earned her MSN in 2016; and Randi Horne (RH), who earned her MSN in 2015.

What was your career path before choosing AGPC?

HW: I started as a licensed vocational nurse and worked my way up through each degree. I worked mostly in the emergency department and surgical intensive care unit and also did some medical malpractice defense work as an RN.

LM: After graduating with a Bachelor of Science in Nursing (BSN) from the Ohio State University, I practiced many years as an RN in areas such as the intensive care unit/coronary care unit; medical-surgical; orthopedics; gastrointestinal; ear, nose and throat; pre-operative; and post-anesthesia care unit. I also worked in management as a nursing supervisor. Nursing has always been a great career for me. I have been able to raise a family and work part time in a job that I loved. Best of both worlds!

LG: I first earned my RN diploma, then received my BSN in 2002. Before switching to my current position, I worked as a nurse clinician/nurse navigator for OHC outpatient oncology group.

RH: After graduating with my BSN in 2007, I joined a general surgery clinic for a Level 1 trauma county hospital in Texas. Those were two years of great learning experiences, including working in orthopedic post-operative acute care, radiation oncology and a cosmetic surgery post-anesthesia care unit.

Why did you decide to become an AGPCNP?

HW: I’m comfortable with adults; children scare me. I have worked my entire career with adults, so that is where I am comfortable.

LM: As a well-seasoned nurse, I realized I wanted to advance my education, have more autonomy and take my nursing career to the next level. A few of my nursing colleagues/friends were returning to school to become nurse practitioners, and I thought this may be a good career enhancement for me, as well. While many people in their 50s are starting to think about retirement, in the fifth decade of my life I made the choice of returning to school. I was excited and motivated to change directions in nursing. School was stressful but became a challenge that I actually enjoyed. I’ll be honest, some days I thought, Lynn, why are you doing this to yourself? But my husband and children were very supportive and encouraged me throughout my days at UC.

LG: I wanted to advance my career and be able to do more for my patients. I knew I wanted to stay in oncology and focus on the adult population.

RH: At the time of my decision, more nurses were enrolling in the FNP program, but I felt the role of AGPCNP was better suited for me because all my nursing experience had been with teen and adult patients. I also wanted to shift to the preventive level of care, instead of acute care. The role of AGPCNP was perfect for my transition from RN to advanced provider before becoming an aesthetic nurse practitioner.

How do you feel the college’s AGPC program prepared you for what was ahead in your specialty?

HW: I was very well prepared. The classes are thorough and the professors are very knowledgeable. They are also very approachable. I felt supported.

LM: The curriculum addressed key areas which prepared me for my profession. My advisor and instructor, Dr. Christine Colella, was very influential in my success. Her enthusiasm, energy and passion for nursing is obvious. She knows how to motivate and inspire students (me) with her approachable, friendly demeanor. She was very supportive during my career as a student.

LG: To rate on a scale of 1–10 with 10 being the best, I rate it at 10. All the professors who worked directly with me also practiced as APRNs. This was very helpful in understanding what reality would be after the program.

RH: The program allowed me to leverage my autonomy while guiding me in honing my assessment, diagnosis and educational skills. The college also accepted clinical rotations in the dermatology and cosmetic surgery office setting, which helped me narrow my field of practice upon graduation.

Share a brief overview of the responsibilities you hold as an AGPCNP.

HW: I am the airway nurse practitioner for Ear, Nose and Throat at University of Cincinnati/UC Physicians for Otolaryngology. I see complex airway patients (stenosis, tracheomalacia, etc.) in clinic and in inpatient settings. I do trach changes, flexible tracheobronchoscopy and video laryngoscopy and manage medications related to the patient’s condition. I also perform a few minor procedures, such as chemical cautery.

LM: My last clinical rotation was in a physician-owned dermatology office in Kenwood, Ohio. I had the good fortune of crossing paths with the great Dr. Bill Kitzmiller, who was one of the leading dermatologists in the city in the ’60s, ’70s and ’80s. He became my mentor and friend. I was hired and stayed at this office for 12 years. Eventually, the office changed hands and a nurse practitioner owned and operated the practice. I worked very autonomously and had my own patient load that I was entirely responsible for. On a typical day, I would see anywhere from 20-40 patients. Some of my duties included performing cancer screening skin exams, biopsies, incision and drainage procedures and intralesional injections. I also treated and followed up on rashes, acne, eczema, psoriasis, skin cancers and many other skin disorders. I maintained prescriptive authority and often prescribed medications. My job required a lot of problem solving throughout the day and enabled me to develop relationships with other disciplines. To further my education and credentialing, I also joined a professional nationwide dermatology association for nurses called the Dermatology Nurses Association. They offered a national certification exam, which I took and passed.

LG: I work in hematology/oncology for the UC Health Barrett Cancer Center and for West Chester Hospital outpatient offices. I see patients on my own and in shared visits with my attending physician, and I work with clinical trial patients. I perform symptom management and evaluation for treatment with chemotherapy/immunotherapy for head and neck, lung and genitourinary cancers.

RH: As an AGPCNP, I have practiced in both the aesthetic medicine and research roles. Initially, I worked for a large multistate med spa directing a team of RNs, LVNs, aestheticians and laser technicians in the care of aesthetic patients. In 2020, I began working as a research NP providing in-home assessments for patients in cardiac and diabetes studies. My newest role as an aesthetic research NP for Allergan Aesthetics with the CoolSculpting® division has merged these two specialties. I assess and clear all patients for numerous aesthetic procedures, such as facial injectables, laser therapy, radiofrequency microneedling, body contouring and cryolipolysis. I also am trained and certified to treat patients in these procedures. My main daily duty is making sure my team follows protocols and utilizes equipment/products appropriately. I am also part of an interprofessional clinical study team, where I monitor patient safety and implement device treatments while utilizing newly engineered device applicators and accessories. My long-term responsibilities include continuously educating patients about procedure maintenance, prescribing medical-grade routine skincare, managing any adverse reactions to procedures or skincare products, learning new procedures and techniques and reassessing if treatment is therapeutic. I also assess usability and feasibility of devices to determine treatment efficacy, which is studied over years with our research and development team.

What have been some of the most rewarding aspects of working as an AGPCNP? On the other hand, what specific challenges have you encountered in this field of work?

HW: The biggest challenge I faced was switching from nurse mode to provider mode — although you’re still focusing on total patient care, you’re placing the orders instead of performing the orders. At first, this was a challenging balance. I would have to say one of the most rewarding aspects is the relationships I develop with my patients. As a nurse, you see them either in clinic or in the hospital. As a provider, I am with them through all aspects of care for their disease process.

LM: One of the most rewarding aspects of working as an NP is creating trusting relationships with patients, families and coworkers. I’ve precepted quite a few NP students, mostly from UC, which I really enjoyed. I strived to create a positive learning environment that was not overwhelming or stuffy and tried to show how we, as NPs, can be such an asset to other health care providers and to our patients. I always enjoyed the growth of confidence and knowledge in my students. Respect for others, accountability and responsibility are utmost in my agenda. I became a nurse to help people and I always strived to do just that.

I’ve learned that being an NP is lifelong learning. The health care field is forever changing, and we must stay current. Specific challenges that I have encountered are with other health care disciplines and some patients with the lack of understanding of the capabilities of an NP. I think there are still a lot of misconceptions and people don’t really understand our scope of practice and how we can complement the health care team. I have high hopes that laws will soon change to allow nurse practitioners to perform independently.

LG: The most rewarding aspect is the satisfaction of taking care of patients and their families by providing compassionate symptom management and education, as well as collaborating with other colleagues. The most challenging aspect is to be respected as a provider.

RH: As an AGPCNP, I have been able to have positive interactions with patients and gain trust by providing high-quality care. In 2020, when I ventured into the role of small business owner (Aesthetic Artist), I partnered with a physician and began a concierge facial injectable and skincare business, which gave me freedom to build a patient roster and treat with products I love and are backed by rigorous research. The challenges I encountered with breaking into the field of aesthetics was timing, patience and required further education outside of grad school because it is a specialty. There is not a strict stepwise plan for aesthetics treatments, which can be daunting at times, but it also allows for my creative side to flourish.

By: Evelyn Fleider