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Coordinators of Care

Family Matters - Winter 2012

Mid-level providers play key 
role for patients


By Lindsey Garner

To Laura Owens, a mid-level provider is a “hero, champion and friend.”

Mid-level provider (MLP) Holly Green, a physician assistant on the surgery team at MD Anderson Children’s Cancer Hospital (CCH), worked in depth with Owens to prepare her and son, Cole, for a surgical procedure.

In 2010, Cole’s desmoplastic small round cell tumor diagnosis was treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. After returning home to St. Louis, Cole developed an infection at the incision site.

Green remained in constant communication with Owens and Cole’s local physicians. Acting as the intermediary between his specialists at CCH and physicians in St. Louis, Green helped coordinate a plan for Cole to get back on the road to recovery.

As with Green’s experience, MLPs are often seen as the “glue” or “go-between” for other medical staff, patients and caregivers. But when one digs deeper, their impact on patient care is far-reaching.

“Mid-levels play a vital role in helping to provide excellent patient care,” says Sarah Bottomley, mid-level provider manager for CCH. “Our focus and training bring a complementary perspective to help address the complex needs of our patients and their families.”

As a mid-level provider, Holly Green has a far-reaching 
impact on patient care at MD Anderson.

Growing in numbers and expertise

During the past 10 years, the number of mid-level providers contributing to patient care at CCH has steadily increased to match the hospital’s childhood cancer patient population, which saw a 30% growth from 2005 to 2009.

In 2001, there were no more than three MLPs at CCH. Today, there are three physician assistants and 11 nurse practitioners (NP).

Green enjoys the intellectual challenge of her job and is inspired by the high caliber of doctors working at CCH, which allows her to continue to advance her skills.

“In the past, we were viewed differently,” she says, looking back at her more than 20 years as an MLP. “It was a paternalistic atmosphere — we were ‘just assisting.’ That outlook didn’t contribute to good teamwork, but things are different now.”

Green says this attitude is no longer the case at CCH, due to the MLPs’ self-confidence and the trust that physicians have in them and their level of expertise.

“Our mid-levels know how to provide the most delicate and specialized types of care,” says Riza Mauricio, an advanced practice nurse in the pediatric ICU at CCH.

Educators and advocates

“As mid-levels, our training and experience provide us the opportunity to serve as educators and advocates for patients and their families, as well as other employees,” Bottomley says.

MLPs provide care that looks beyond the disease process and is more holistic and family-centered. Including the family and caregivers in the treatment process, and at a level that is accessible to a lay population is essential, Bottomley says.

Complementing this strength is the keen ability of MLPs to address patient needs by incorporating other disciplines into the treatment process, such as support programs and psychological services.

The theme of education continues in the relationships MLPs have with staff members. They collaborate with nurses, specialists and technicians to bolster their skills and knowledge base and provide educational opportunities.

Mauricio knows firsthand how training can help staff. In 2005, she assessed and identified the needs of nurses and respiratory therapists in the ICU. This led her to collaboratively develop an annual three-day workshop, where experts from 
MD Anderson and nearby institutions present on the human body systems coupled with training at the bedside.

“Every day presents an opportunity for all of us to learn something new,” Mauricio says. “But with this training, they’re empowered with knowledge and skills that give them confidence in the work they do.”

More than support

Working in tandem with faculty, each MLP’s role differs slightly within each team at CCH. However, what’s similar is that they all act independently and interdependently within their teams.

“We’re more than liaisons between our faculty, patients and their families,” says Mauricio. “We make sure that there’s movement and progress — we’re coordinators of care.”

Within the hospital, MLPs frequently participate in the development of protocols, policies and procedures to aid in improving efficiency and standards of care for patients. This is true even for routine tasks, like drawing blood.

Previously, volumes of blood drawn for lab tests were equivalent to those used for adult patients. Mauricio felt that this experience could be made more pediatric-friendly and created a task force with faculty, nurses and lab techs.

Collaboratively, they established a new policy for pediatrics on how to draw blood, minimizing the stress placed on patients and making the process more efficient.

Room to grow

With a career in oncology that spans 25 years, Bottomley has seen the presence of MLPs in this specialty grow.

She expects that the reliance on and need for MLPs will continue to increase because of likely future gaps in patient access to care. This is primarily due to factors such as health care reform, the decreased availability of medical residents and a growing patient population.

In fact, there’s already a need for additional MLPs at the Children’s Cancer Hospital. Two NP positions were recently available — one for inpatient care and another in the pediatric ICU.

With MLPs poised to take on more responsibilities, Bottomley finds reassurance in knowing that “our roles are nicely supported and valued within the institution, and I feel they will continue to be.”

Owens values Green’s role in helping Cole get on the path to becoming cancer free.

“Holly helped see us through every challenge,” she says.

After overcoming many challenges, 10-year-old Cole is healthy, back to playing baseball, a straight A student and having fun “just being a kid” on his school breaks.

Patients Count on Award-winning Green


When patients call, Holly Green responds.

As a physician assistant (PA) for 24 years, including 16 in public health and eight at MD Anderson Children’s Cancer Hospital, Green makes it a priority to be available for patients and their families.

For that reason and much more, she has received MD Anderson’s 2011 Geneva and James Briscoe Physician Assistant Award for Excellence.

The honor recognizes PAs who excel in their clinical role, deliver quality patient care, demonstrate a commitment to research and education, and serve as an inspiration to others.

In a nomination letter to the selection committee, Andrea Hayes-Jordan, M.D., says her patients can page Green at any time to answer questions.

“Every one of my patients has commented on how critical she is to how well our pediatric surgeons function,” says Hayes-Jordan, associate professor in the Department of Pediatrics. “There are no gaps in what she can or can’t do.”

A parent of one of Green’s patients also recognized her for being available, saying Green is “… a consistent, reliable source of information, assurance, assistance and kindness.”

The mother detailed how Green supported her child and family by answering questions and solving problems whenever they needed her.

A committee of clinical faculty, previous award winners and administrators from MD Anderson selected Green. She received a $3,000 cash award donated through the Briscoe estate.


© 2014 The University of Texas MD Anderson Cancer Center