Strengthening Headache Care Through Structured APP Onboarding

A recent publication in Headache: The Journal of Head and Face Pain highlights the growing role of advanced practice providers (APPs) in U.S. headache medicine and proposes a framework to improve and standardize their clinical onboarding. The manuscript “Towards a Standardized Process of Onboarding Advanced Practice Providers into Headache Medicine Practices in the United States: Expert Consensus from the American Headache Society Practice Management Committee” was authored by Calli Cook, DNP, Brad Klein, MD, and Marius Birlea, MD, members of the APP Work Group of the AHS Practice Management Committee. The article offers expert consensus guidance on APP training, covering supervision, education, procedural skills, and scope of practice to promote consistency and high-quality care.

As the demand for headache care continues to rise, APPs play a critical role in ensuring patients receive timely, specialized treatment. Yet onboarding practices vary widely across the country, which the authors identified as the primary motivation for this project. As Dr. Klein explained in the interview, “By trying to create a standardization across the country, we can try to ensure that quality care is the same across the country.” Structured onboarding benefits patients, helps APPs feel confident and supported, and gives supervising clinicians a clear framework for training and collaboration.

Watch the full interview with the authors:

The authors clarify that this publication is not an evidence-based guideline, but a set of best-practice tools informed by expert consensus and survey input from AHS physicians and APP members. Their work aims to capture diverse perspectives from the clinical team and address the challenges of integrating APPs that are trained in generalist models into the highly specialized field of headache medicine. While the article briefly touches on administrative considerations, its primary focus is on clinical onboarding and establishing the educational foundation necessary for high-quality specialty care.

Through a structured consensus process, the committee addressed core aspects of APP onboarding, including its recommended duration, supervision expectations, procedural training standards, and essential curriculum components. The resulting curriculum is intentionally comprehensive, reflecting the complexity of headache medicine.

As Dr. Birlea explained, “our goal was not to have it covered during the duration of onboarding, but to serve as a guide for the new APP for the preparation, potentially set some expectations. And we don't require mastering of all these elements in the curriculum by the end of the onboarding.” This approach sets foundational expectations while allowing flexibility, ensuring APPs receive the essential knowledge needed for high-quality care.

The authors also acknowledge that implementation may vary across academic and private practices, adult and pediatric settings, and clinics of different sizes. While challenges such as compensating lead clinicians overseeing onboarding may arise, the group emphasizes that a systematic approach is far preferable to informal or inconsistent processes. Dr. Klein highlighted that evidence shows structured, specialty-specific training benefits practices financially and through improved quality of care, increased clinician confidence, and expanded patient access.

The publication also emphasizes the cultural and relational aspects of team-based care. As Dr. Cook shared, “When we create an onboarding plan like we've outlined, you're investing in that member of your team.” She added, “When we think about retention and what that investment looks like long-term, that's really important because not only are we looking at quality, which is an essential component of care, but then we're also looking at what does the long-term relationship with this person look like?”

These perspectives highlight that structured onboarding is about more than developing clinical skills. It also builds strong professional relationships, encourages collaboration, and fosters a culture in which APPs are recognized as valued members of the specialty care team. Setting clear expectations and shared standards can help close perceived gaps between APPs and physicians, promoting alignment within headache medicine practices.

Headache serves as a leading platform for advancing research, education, and clinical excellence in head and face pain. This consensus statement underscores the Society’s commitment to supporting the growing headache medicine workforce and maintaining consistent quality of care. The authors hope the recommendations will spark continued dialogue within AHS and beyond, potentially serving as a model for other specialties integrating APPs into subspecialty practice. It also offers a flexible roadmap for practices seeking to strengthen onboarding, elevate training, and improve care delivery. As Dr. Klein shared, the group is excited for clinicians to read the article and consider how its recommendations can be implemented to continue advancing excellence in headache care.

Read the Interview Transcript:

Dr. Rashmi Halker Singh:
I'm Rashmi Halker Singh. I'm the deputy editor of Headache, and it's my pleasure today to be joined by three colleagues, members of the Practice Management Committee of the American Headache Society, who are authors of a recent publication entitled Towards the Standardized Process of Onboarding Advanced Practice Providers into Headache Medicine Practices in the United States: Expert Consensus from the American Headache Society Practice Management Committee. So welcome to Cali Cook, Marius Berlea, and Brad Klein. I'm so happy to speak with you all about this recent publication.

Dr. Marius Birlea:
Thank you for talking with us.

Dr. Calli Cook:
Yeah, thank you so much, Rashmi.

Dr. Brad Klein: Thank you.

Dr. Rashmi Halker Singh:
So first of all, can you tell me about what prompted you all to do this really important project? What was impetus?

Dr. Brad Klein:
Well, thank you, Rashmi. I think we all understand that advanced practice provider training is so critical to headache care in this country, and we want to make sure that there's certainly an understanding of how to care for these patients most effectively. And we understand that there's also a lot of variability across the country and how that training takes place. So by trying to create a standardization across the country, we can try to ensure that quality care is the same across the country. And that also not only helps our patients, but also helps advanced practice providers make sure that they understand they feel comfortable, they feel confident in the care that they're providing to the patients.

And also for the neurologists who might be training advanced practice providers or other APPs training other APPs, that we understand how to make that happen, so that way APPs can really provide the best care that they can for all patients and everyone can feel more comfortable that APPs can also provide excellent care to those patients.

Dr. Rashmi Halker Singh:
I love that. So truly, it really does help the physician, the advanced practice provider, and also ultimately the patient is who benefits from this work.

Dr. Brad Klein:
Absolutely.

Dr. Rashmi Halker Singh:
So tell me, as you look at these recommendations, what are they? Can you give us a high-level overview of what you all came together with?

Dr. Marius Birlea:
If I can go first. The recommendations are actually some guiding tools. I want to emphasize these are not evidence-based guideline recommendations, but we think these are best practice tools for headache medicine practices across the country to use. As Dr. Klein was mentioning to standardize the onboarding and we talk here about the clinical onboarding, while in the paper we touched a little bit about the administrative aspects of the onboarding, we thought it was important for us to emphasize some of the needs that we think are there in terms of training the APPs in headache medicine. And through some process that is described in the paper, and we can elaborate on if time, we came up with a few important questions.

For example, what's the duration of the onboarding? What does it mean to supervise an onboarding APP? What is required for the formal education in that? What's the standard that's recommended or expected for procedures? And then what's the curriculum? So these are the few important questions that we try to answer.

Dr. Rashmi Halker Singh:
So you shared that these are not evidence-based guidelines. So, in that sense, how was the decision made to come up with these specific recommendations?

Dr. Calli Cook:
So I can talk a little bit about that. As a group, and thanks for that question, we really wanted to think about every perspective of the clinical team. And we represented the APPs and our physician colleagues well in this, and we looked at what do we need for a smooth transition of practice, and what does a transition of practice mean for an APP in headache medicine? And when you think about the way APPs are trained, which is in a generalist model and how specific headache medicine is, we knew that we needed not just administrative functionality for onboarding, but also clinical. And as Marius mentioned, procedural, all of these ongoing education interventions for the APP.

So as a group, we looked at what was available, and then we also created a survey and we sent it to both our physician and APP members within American Headache Society to better understand what they thought was needed. So this is expert consensus from the practice management committee, as well as a survey of our members to better understand the need of this particular community.

Dr. Rashmi Halker Singh:
I love the diverse perspectives that we're taking into account. And it really seems like everyone who is really at the front lines, their experiences were brought into this as well. So I think that's really important to highlight. What might be challenging to implement as you all think about the work that went into this and think about the clinicians who might be needing to use these recommendations?

Dr. Marius Birlea:
What motivated me to get into this project, except saying yes to my boss here, was that I was dissatisfied with the onboarding of APPs in my own practice. So I really thought that there is a lot of work in doing this. I think the main challenge is to get into implementing into various practices because there are academic practices, private practices, larger practices, smaller practices, pediatric, adult. So with the recommendation, we wanted to offer some flexibility for individual practices to adjust the recommendation according to their own situation. So I think that would be the main challenge. Plus, the distribution of recommendations.

One of the questions we had from the reviewers was, who is going to pay for this? I think there are some challenges with that. And the lead clinicians, what we outlined in the paper that oversees the onboarding process may need to be compensated for the time and for potential loss of productivity. But I think all these things are doable and the systematic approach is preferable than leading it to the individual practices. Dr. Klein?

Dr. Brad Klein:
Yeah, there is a plethora of data though that supports if you provide the right training to advanced practice providers in headache care, that return on investment is manyfold more, not just from a financial standpoint, but certainly from a quality of care standpoint, the confidence that you could have in that advanced practice provider to provide appropriate patient care, the confidence that you can know that they can take care of those patients without much involvement of you necessarily, and improving access into your community for headache care.

So there are many great reasons why providing the right type of training has such a significant value in this conversation. And I don't think that anyone should be shirking on ensuring that the people that are going to be entrusted to provide patient care should be less than that level. So I think this does raise the bar a little bit, but I think ultimately, I think we'd all agree in the medical community that we want to strive for excellence when we're providing care for our patient population. So while there are going to be some challenges to get to that level, I think there's some value in always trying to aspire to that level as we go forward.

Dr. Rashmi Halker Singh:
You all make such excellent points.

Dr. Calli Cook:
I'd like to add one thing. I also think that this paper touches on the cultural needs of the clinic and the community, and how relationships are really important. Because when we create an onboarding plan like we've outlined, you're investing in that member of your team. And when we think about retention and what that investment looks like long-term, that's really important because not only are we looking at quality, which is an essential component of care, but then we're also looking at what does the long-term relationship with this person look like? And are we building the culture that really emphasizes what we want when we dive into practicing team-based care?

Dr. Rashmi Halker Singh:
Oh yeah, that's a very good point as well. You've raised such important points. And another thing, what do you all know about the American Headache Society providing additional support and resources to support this initiative? And this whole, the physician, and the APP, this model, are there things that AHS is doing as well?

Dr. Marius Birlea:
So I think it suggested to us that we can make things like an infographic that utilizes social media to promote our work and recommendations, but I personally haven't done much of that with anything else.

Dr. Calli Cook:
I think that the AHS has created a platform for APPs, which is important. Seeing them as a valued member of the society is key. And as we see the roles of APPs become more common in specialty practice, the emphasis on including APPs within societies or academies of specialty practice is really important because again, when we think about relationships, we think about teams, wouldn't you want to go to a conference with your whole team? I mean, isn't that the point? So I think that is something that AHS has done well, is having the APP group and having a place for APPs within the society.

Dr. Brad Klein:
And I think it's also really important just to comment on what Calli said, that by having APPs part of the organization, by having neurologists and APPs, and other physicians and other clinicians and other stakeholders involved in the American Headache Society working with APPs, that just expands the dialogue, the conversation to help us figure out how do we do this best? How do we take care of our patients best? And so I think this paper will help pursue that whereby people will dialogue about it more, perhaps discuss it at the conferences, maybe even present a presentation on it, where people will become more exposed. And we can have that dialogue, of course, as to does it need to be fine-tuned as we go? Is this where we're trying to aspire to the best? So there's lots of different opportunities, I think the American Headache Society can continue to offer work like this.

Dr. Marius Birlea:
One more word, Rashmi, if I may?

Dr. Rashmi Halker Singh:
Yes.

Dr. Marius Birlea:
I do perceive, and Calli, you can tell me if I'm wrong, that there is a gap between how APPs perceive themselves in relationship to the MD physicians. And I think this paper has contributed a little bit to closing the gap. And one word about the curriculum is pretty extensive and complex. And another concern that was expressed is that to cover all the curriculum is going to take a year of full fellowship. Yes, raises the bar a little bit, but I think it's important to try to contribute to filling that gap.

And our goal was not to have it covered during the duration of onboarding, but to serve as a guide for the new APP for the preparation, potentially set some expectations. And we don't require mastering of all these elements in the curriculum by the end of the onboarding, but some that were specifically mentioned like ICHD main criteria for primary headache disorders that are important, red flags, indication, contraindication, side effects of main medications and procedures. So I think it's reasonable and doable.

Dr. Rashmi Halker Singh:
Yeah, I support what you're saying. Any additional thoughts or things that you want to share with the audience?

Dr. Brad Klein:
I would say, if I may speak for all of us, I think we're all very excited for people to read the article to see how they can implement that in their practices and really continue raising the bar.

Dr. Marius Birlea:
I also hope that the audience is going to be beyond AHS. I think this can be a model for other specialties on the approach that we suggest for onboarding of APPS into headache medicine for these examples, but not only.

Dr. Calli Cook:
Yeah. And to that point, this is an invitation to APPs to consider headache medicine, to consider neurology, that there are groups of people that are interested in taking this person who's trained in a generalist model to something specialized that they have a specific passion for working with people who have headache disorders or neurologic concerns. So I think that's very exciting as an APP.

Dr. Rashmi Halker Singh:
I want to thank you all for your work. This is such an important contribution, and so thank you so much for providing this framework for all of us.

Dr. Marius Birlea:
Thank you very much.