The career paths that respiratory therapists can take have always been vast and varied, but one destination was historically outside of their reach — that of the advanced practice provider. While RTs could leave the profession to enroll in a nurse practitioner or physician’s assistant program, there wasn’t a direct route from their undergraduate degree to advanced practice within respiratory care.
That all began to change about ten years ago when the AARC, NBRC, and CoARC teamed up to investigate the feasibility of establishing an Advanced Practice Respiratory Therapist (APRT) role in the profession. Now the VA Maryland Health Care System (VAMHCS) has taken the concept a big step further, becoming the first organization in the country to create an official APRT role within its system.
Daniel Whitt, BHS, RRT, RRT-ACCS, RRT-NPS, chief of respiratory therapy at VAMHCS, spearheaded the effort.
Establishing the framework
Whitt was spurred to act after the Veteran’s Integrated Services Network for his region (VISN 5) put out a call for joint proposals for improvement last year. He was aware of the APRT and thought it would make a good addition to the services the Veterans Health Administration (VHA) provides to the nation’s veterans of service.
His draft proposal touting the APRT concept was submitted last November and included an “ask” for the group to examine the utility of having APRTs serve as advanced practice providers within the Department of Defense and the VHA. “I served as facilitator of this effort within the Veterans Health Administration and worked to bring together stakeholders and key opinion leaders to establish the framework for the announcement of the APRT position,” said Whitt.
Whitt turned to his colleagues in the AARC for assistance in gathering the supporting data that would be needed to bring the idea to fruition. William L. Croft, EdD, PhD, RRT, FAARC, executive director of the North Carolina Respiratory Care Board, played a big part in that endeavor.
“Daniel was referred to my Board and me in November of 2022 about our efforts regarding the APRT by Tom Smalling with CoARC,” explained Dr. Croft. “Their goal was to establish this position in the VA system since there is a shortage of primary care providers.”
Dr. Croft provided Whitt with all of the information his Board had accumulated since 2018 so that Whitt and his colleagues at the VA could develop a job description.
“Our initial response was based on the 2018 Advanced Practice Respiratory Therapists Declaratory Ruling, which is now the Advanced Respiratory Care Practitioner Declaratory Ruling,” he said. “In addition to the 2018 ruling, we provided all of the materials we had developed for the North Carolina General Assembly in preparation for the upcoming session.”
The materials were presented to the General Assembly in support of legislation aimed at adding the APRT to the North Carolina RT practice act and took the form of a needs assessment outlining the value that the APRT position could add to the care of patients in North Carolina. The materials were based in part on an AARC-led survey of 1,401 physicians that sought to identify whether physicians perceived a workforce gap that could be filled by a respiratory-specific advanced practice provider.
Results showed 74% of the physicians agreed or strongly agreed that there would be a future need for a non-physician advanced practice provider with cardiopulmonary expertise. The investigators concluded that efforts to continue the development of this role should continue.
Crafting a job description
Whitt took the information provided by Dr. Croft and worked with his colleagues to craft a job description specific for the VAMHCS. After he sent Dr. Croft his initial draft, Dr. Croft and others on the AARC’s APRT, Credentialing and Education Committee, including Sarah M. Varekojis, PhD, RRT, RRT-ACCS, FAARC, a clinical professor and director of clinical education at Ohio State, and David Vines, PhD, RRT, FAARC, FCCP, chair of the department of cardiopulmonary sciences at Rush University, provided feedback that figured into the final job description that was approved by the VAMHCS.
“The APRTs practicing within the VAMHCS will be responsible for identifying, diagnosing, and managing cardiopulmonary disease and/or disorders of the veteran beneficiaries they serve,” said Whitt. “As such, APRTs will employ methods and other advanced practice modalities that assist in the diagnostic discovery of underlying cardiopulmonary disorders.”
These practitioners will differ from current RTs in several ways, continued Whitt, particularly in terms of identifying, diagnosing, and managing cardiopulmonary disease and/or other disorders veterans may be suffering from. APRTs will serve as physician extenders capable of making independent decisions in certain circumstances and aid in the diagnosis of disease.
APRTs at the VAMHCS will also take on a range of supervisory responsibilities and will participate in care planning along with physicians, nurses, and care staff.
Whitt and his colleagues believe the position can enhance access to specialty care and pulmonary services across the VAMHCS in part by reducing wait times and increasing the number of face-to-face visits veterans can receive. APRTs will also be able to support home-based primary care models.
“Outcome measures and secondary endpoints related to wellness will be evaluated to demonstrate benefit and the value added by the Advanced Practice Respiratory Therapist, with the goal of building and refining a care model across VISN 5 as a best practice,” said Whitt.
The VAMHCS APRT position was officially announced in January, and Whitt anticipates that the experience the health care system has with the position will play a big part in its spread to other VA medical centers throughout the Veterans Health Administration.
“We believe this effort could be replicated at VA medical centers across the country that offer specialty care services,” said Whitt. The functional statement has been classified and approved for use and forwarded to VHA National Program Director for Pulmonary Critical Care Claibe Yarbrough, MD.
“VA medical centers interested in implementing APRTs as part of their organization model may reference this document to solicit and recruit graduate Advance Practice Respiratory Therapists,” he continued. “The impact would be profound as the demand for APRTs could far exceed the resources currently available.”
CoARC has established a minimum of a master’s degree for advanced practice respiratory therapists. Right now, there is only one APRT program (at Ohio State), and that program has graduated only 11 clinicians, with another three to walk the stage this year, so challenges certainly remain. But they are challenges that the AARC and its APRT committee are ready, willing, and able to take on.
“We hope that the APRT position’s growth can be staged so that the VA in states with universities interested in starting an APRT program can add these positions,” said David Vines, who co-chairs the committee along with Bill Croft. “It would provide the needed incentive for universities to move forward with creating an APRT program.”
Sarah Varejokis, who works with students in the APRT program at Ohio State, agrees. “There is hope that the creation of a practice opportunity within the VA will encourage the development of additional APRT education programs,” she said. “The CoARC APRT Standards provide an excellent resource for programs interested in developing a new program.”
She recommends that colleges and universities with an interest in developing an APRT program of their own do a thorough resource assessment to ensure they have access to all of the components necessary for success. Generating support from physicians will be crucial as well because they will be needed to provide assistance with the APRT educational program.
“Physicians have expressed interest in an advanced practice provider with cardiopulmonary expertise that would help them meet patient demand,” said Dr. Varejokis. ”The APRT will improve access to care for cardiopulmonary patients with unmet patient care needs.”
NC program waiting in the wings
In Ohio, Dr. Varejokis and her colleagues had to make their way through six different committees at the university level to gain approval for their program and then acquire approval from the Ohio Chancellor’s Council on Graduate Studies before they could seek CoARC accreditation, so the process is clearly long and arduous.
In North Carolina, Bill Croft and his colleagues are going through a similarly rigorous process now. In January of 2021, the North Carolina Respiratory Care Board voted to introduce language into the existing RT practice act that adds an Advanced Practice Respiratory Care Practitioner (APRC) akin to the APRT to the state licensure law. If the Respiratory Care Modernization Act is passed, APRCs with a master’s degree in an accredited APRT program could act as specialized assistants to physicians.
As with VA, the goal would be to create a physician extender who could provide more timely care to patients, especially in rural areas, reduce the amount of time spent waiting for a physician in cases where changes in life support are required, and deliver an expert level of care to a range of settings, including the home.
Dr. Croft and his colleagues have looked closely at hiring data in their state as well, and have concluded that job prospects for an advanced practice RT would be good. He believes the first APRT program in his state will come online at the University of North Carolina Charlotte sometime in 2025.
Action plan in place
Another APRT program would definitely be a step in the right direction, but Dr. Croft agrees with his colleagues on the committee that there is much work ahead to ensure every organization interested in hiring an APRT can find one. Adding the role to existing state licensure acts will be key to success because other advanced providers are licensed. But it won’t be easy, given the dearth of educational programs.
“We faced a different dilemma 30 years ago with initial licensing,” said Dr. Croft. “We had colleges and practitioners, but hospital lobbying groups often opposed us, so many bills took years to pass.”
This time around, it will be the lack of colleges and practitioners that will slow things down.
“While we have a handful of graduates from the Ohio State program, it will not be enough to convince the other states to take up the APRT as we did with initial licensing,” said Dr. Croft. “We cannot expand the APRT concept too rapidly without having programs.”
Dr. Vines says the committee already has an action plan in place to make that happen. “The plan focuses on licensing, program development, credentialing or end-of-the-program assessment examination, outcomes, and reimbursement for services provided,” he said. “For this year, the first three are our primary focus.”
He also says the committee will be working to identify four or five other universities interested in getting started on an APRT program. “Then we will work with these universities interested in developing a program and their state societies to begin the legislative process at relatively the same time,” said Dr. Vines.
The VA Maryland Health Care System’s approval for an APRT position may just be the shining example that will spur these organizations and their state governments into action. It’s already happening in North Carolina. “Our legislative efforts have been bolstered by this development,” said Dr. Croft. “We were able to secure three primary sponsors for the bill in one day. The news of Daniel’s success has spurred great interest in my contacts at the North Carolina General Assembly.”
As for Whitt himself, he says the VAMHCS feat was a team effort and he cannot take the credit, but it is clear that his initial action — i.e., seeing a call for proposals and taking a leap and suggesting the APRT could fill a need — got the ball rolling.
“The VA Maryland Health Care System department of pulmonary and respiratory care is looking to enhance care delivery to veteran beneficiaries across the state,” he said. “We hope to lead the nation in demonstrating the value in utilizing the Advanced Practice Respiratory Therapist in the diagnosis and management of conditions associated with cardiopulmonary health and wellness across all care settings.”
- Visit the AARC’s APRT page to read more about the position and access a list of frequently asked questions.
- Go here to read a booklet prepared by the North Carolina Respiratory Care Board titled, “The Advanced Practice Respiratory Therapist: A New Physician Extender.”
- Listen to this podcast to hear Daniel Whitt, Bill Croft, and David Vines talk about the VAMHCS journey to the APRT.
- View CoARC’s Accreditation Standards for Advanced Practice Programs in Respiratory Care here.
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