Modernizing the Advanced Practice Provider Role for GU Oncology Patients

By Rachelle Rodriguez, MS, APRN, AOCNP, Zachary Bessette - Last Updated: March 6, 2023

In January 2023, Rachelle Rodriguez, MS, APRN, AOCNP, the genitourinary (GU) advanced practice provider (APP) supervisor at Moffitt Cancer Center, was honored by Moffitt with the Award of Excellence in Innovations in Clinical Care.

GU Oncology Now spoke with Rachelle regarding her role in helping Moffitt grow its APP presence within the GU oncology program as well as the specific challenges for APPs in their treatment of GU patients.

Can you tell us about your journey at Moffitt to date, from your initial role as an inpatient surgical APP to the events that led to developing this APP department for GU surgical patients? Why was this role needed?

Rachelle: I began at Moffitt in February 2017. At the time, there were 2 available positions within GU, inpatient and outpatient supporting one of the surgeons. I was offered whichever position I preferred. At that point, my background had been in working as a charge nurse in inpatient with surgical and medical oncology patients, so my heart was definitely in inpatient.

In those days, we had 5 surgical oncologists within the GU program, 2 medical oncologists, 3 outpatient surgery APPs, and 1 medical oncology APP. We were also recruiting a fourth outpatient surgery APP. The inpatient role had previously been managed by our fellows, residents, and attendings. Some of the outpatient APPs assisted with consults throughout the day, but there was not any dedicated support in that role.

When I started as the first inpatient surgical APP, I was basically told, “You can make this inpatient role whatever you see fit.” I relished the challenge and opportunity; I liked having the freedom to figure out how I could be useful and what impact I could have within our program and with the patients.

Immediately, one of my key responsibilities included taking over the management of all our inpatients. They were still seen by our attendings and our fellows and residents, but I took over the day-to-day care. I’d see all of them every day, handle their discharges, and lead them throughout their hospitalization. Any time there was a new consult—whether it be from urgent care or our other departments in the hospital—I staffed them. If we needed to admit patients from our clinic or from home, it would be on me to do so.

By the beginning of 2018, we were starting to look at different metrics within our inpatient role. I was chosen to be on a committee for GU-specific metrics, focused on the geometric mean length-of-stay and actual length-of-stay. At that time, I had to take medical leave for 4-6 weeks, and during my absence, the data showed our mean inpatient length-of-stay increased almost 2 days. In other words, my absence had contributed to significant avoidable days in the hospital.

These metrics were the hard-data proof of my benefit to Moffitt as an inpatient APP. The timing was perfect. From then on, various surgical departments within Moffitt began adding surgery APPs. Nowadays, I manage all the APPs in the GU department and spend about 50% of my time with GU inpatients and 25% of my time with GU outpatients. The inpatient APP role within GU has continued to grow and allows our team to be involved with interdisciplinary rounds, daily rounds with patients for continuity of care, and early intervention based on exam findings and results throughout the day while attendings, fellows, and residents would otherwise be tied up in surgery or clinics. Our involvement also leads to fewer interruptions to providers, residents, and fellows during their day for improved work-life balance.

Your role today includes overseeing the APPs in GU medical oncology, outpatient surgery, and inpatient surgery as the GU APP supervisor. What are your day-to-day responsibilities? How many APPs do you oversee, and how hands-on are you?

Rachelle: I work mostly on the inpatient side but also cover outpatient clinic, and as the supervisor I have some built-in administrative time. To break it down by percentages, 50% of my time is dedicated to inpatient, 25% to outpatient (usually in provider clinics), and the remaining 25% to administrative duties.

Currently, we have 9 surgeons, 5 medical oncologists, and a total of 15 APPs within GU (including myself). Of those 15 APPs, 7 are surgery APPs (2 of whom assist in the operating room), 4 are medical oncology APPs, 2 are additional inpatient APPs, and 1 is a hybrid APP who helps with new patients as a first point of contact.

Whenever there are gaps in the team, whether it be unplanned absences or paid time off, I fill in, so I manage to stay very hands-on.

Can you describe some of the unique struggles or pain points in the life of an APP for GU oncology patients?

Rachelle: For starters, we manage a busy clinic, and it is always busy. GU patients tend to be complex cases, and careful management is absolutely crucial. On the surgery side, our APPs have to be pretty hands-on with administering the care these patients need. Many patients require surveillance, which includes routine imaging and checkups to monitor for recurrence. It is often an APP these patients are seeing for this type of care.

On the medical oncology side, our APPs are following patients throughout their treatment journey. We are seeing them during high and low points of their continuum. It can be challenging, emotionally draining work, but many APPs will tell you it’s the reason they do this job. They enjoy seeing patients through their care, through the highs and lows, because they feel a real purpose and value to their work.

How big of a priority is it for your APPs to stay current with the literature, research, and guidelines?

Rachelle: Our APPs are involved in journal clubs, both on the surgery side and the medical oncology side, as well as some general ones we do for GU-specific topics. Since Moffitt is a research hospital, there’s lots of trials and research happening right here that our patients should have access to. There’s all sorts of materials to stay up to date on, including conferences or continuing medical education events they are attending on their own, and also faculty presentations during tumor boards or group meetings.

From your perspective, what are the largest or most noteworthy barriers to optimal care for GU oncology patients? How are you helping to overcome those barriers at Moffitt?

Rachelle: A few years ago, one of the big barriers we had was of course COVID-19. For us, it was about getting patients in, seeing patients, making sure they got the surgery and the procedures they needed, and continuing to do so safely during a pandemic. However, COVID-19 hit at a time when we were already looking to expand virtual care, so the timing was somewhat of a silver lining for us. Since then, virtual care has become a pillar of our care at Moffitt, and we are now well versed in determining which patients are eligible and would be best served virtually. Florida is a large state, and being in the center of the state, Moffitt is well positioned to utilize virtual care to care for more patients than would traditionally be able to walk through our doors.

Another challenge to optimal care is managing our direct referrals and other new patients and making sure they are scheduled or seen within 5 days. That is our institution-wide goal at Moffitt, and it comes with the challenge of ensuring that all new patients are seen by the proper team and leave with a treatment plan. At a large institution like Moffitt, this is easier said than done.

In the GU department, we have a pathway in place for our “First Connect” APP to connect with the new patients (via Zoom or phone) and ensure an appointment is scheduled appropriately within 24-48 hours of getting their referral. This APP is also tasked with answering initial questions and soothing their anxieties about the new appointment as well as facilitating any additional work-up that would be beneficial prior to the appointment.

How would you describe the willingness among GU patients to be seen virtually rather than in-person? As a group, are they transitioning to this style of care with ease or is it a struggle?

Rachelle: The GU population as a whole is fairly split down the middle. When I am in clinic seeing patients and they would be eligible for virtual care, I will usually ask, “Have you done a virtual care visit?” Many of them already have done virtual visits, so there is not much resistance to it. In fact, the patients who have previously been scheduled as a virtual visit usually want to stay that way.

Our APP satisfaction scores are pretty similar regardless of whether the visit is virtual or in person. Every 3 months, I reassess the utilization of our templates and our metrics, and each time our APPs are expanding their virtual care templates because they’re increasing their number of virtual appointments. While there are some patients who would rather come in and see us face-to-face, there are just as many patients who absolutely prefer staying home for their care.