The COVID-19 pandemic has increased demand for primary care services while limiting clinic and provider ability to accept new patients. As demand for primary care grows, new models are urgently needed that can increase access to care while efficiently identifying and addressing care gaps.

The MAHEC Family Health Center new-to-practice adult 18+ patient visit process was identified as an opportunity to improve clinic efficiency and increase scheduling capacity with RN same day pre-visit planning. Due to the pandemic, new-patient-to-clinic visits mid-year 2020 were scheduled as telehealth encounters only.

Consistent reduction in provider time from 40 minutes to 20 minutes for a new-to-practice adult 18+ encounter would allow for an additional scheduling slot opportunity. Adding at least one new to practice adult patient scheduled encounter per day for the four telehealth service-assigned providers would significantly increase new-to-clinic patient access.

A same-day pre-visit planning workflow was developed that uses the RN to full practice scope, provides consistency in assessment and charting, and provides an opportunity for the RN to share information in the SBAR format to the provider. The RN scope of practice introduces robust assessment capabilities to efficiently identify patient needs and care gaps while meeting identified MAHEC provider needs for consistency in medication review and review of systems. Data was collected over the course of 35 patient encounters including provider time in visit, gaps in care identified and addressed, and RN and provider collaboration with warm handoff.

The initiative demonstrated that provider time in telehealth new-adult patient encounters can be reduced below 40 minutes while increasing consistency in recognizing and closing gaps in care. Utilizing RNs for new patient intake provides the scope of practice element necessary for ensuring consistency in medication review and review of systems components of the work-up. Workflow standardization was shown to be crucial for consistency in data gathering, risk assessment screening, and EHR documentation. RN handoff communication to the patient’s provider increased provider perceived ability to focus on the patient’s primary reason for visit and to perform diagnostic work and planning. Study data has informed MAHEC Family Medicine clinical leadership decisions in the development of patient intake standardized EHR documentation accompanied by job aids and training for all clinical staff and providers.

This RN-led process increased access for patients, consistently identified and closed gaps in care, and increased collaboration between clinical staff and providers.

References

• Lin, S. Sattler, A., Smith, M. 2020. Retooling Primary Care in the COVID-19 Era. Mayo Clinic Proceedings. 95 (9), 1831-1834.
  
• Sinsky, C., Sinsky, A. MD., and Rajcevich, E. 2015. Putting Pre-visit Planning Into Practice. Family Practice Management. 22 (6) 30-38.

The authors wish to thank Suzanne Shapiro and Brenda Benik for their assistance with the presentation.

Purpose: This project aims to provide care coordination and transition management (CCTM) education and training to pre-licensure nursing students to strengthen preparation of students to practice in community-based ambulatory care settings.

Background: The current state of the health care system has shifted many roles for nurses from hospital settings to ambulatory care and community settings to meet patients' needs across the care continuum. These nursing roles require the development of unique knowledge, skills, and attitudes to improve CCTM in these environments. Few pre-licensure programs offer intentional education and training opportunities in ambulatory care settings. Through funding from the Health Resources and Services Administration (HRSA), a university-based school of nursing developed and implemented a comprehensive curriculum that includes didactic, clinical, and simulation components to strengthen pre-licensure nursing students' knowledge, skills, and attitudes for success in ambulatory care settings. This poster reports on learners’ perceptions of how the enhanced curriculum impacted their knowledge, skills, and attitudes toward ambulatory care in the didactic and clinical courses.

Methods: AAACN's Core Competencies for Ambulatory Care Nurses and Core Curricula in Ambulatory Care and Care Coordination and Transition Management were used as guides to develop the curriculum. Course objectives and outlines were created using an iterative approach with the grant team, comprised of educators and clinicians with expertise in CCTM, which were then reviewed by clinical partners to ensure relevancy. Similarly, topics for case studies were collaboratively identified and developed. Knowledge (competence), skills, and attitudes of learners were evaluated using the following measures: 1) a modified self-efficacy and performance in self-management support (SEPSS) survey (perceived competence) administered pre- and post-course, 2) a modified health care access tool that tracks the type of ambulatory care nursing experiences and skills during clinical (perceived skills), and 3) student reflections (attitudes). Data will be analyzed using descriptive statistics and thematic analysis. Enhancements to the accelerated BSN program were integrated into the clinical practicum experience and through didactic content in CCTM. Enhancements to the BSN program are being incorporated via an ambulatory care clinical course and a CCTM didactic course.

Results: A total of 63 students participated in the curriculum in spring/summer 2020 and another 80 students are currently engaged. Preliminary examination of pre- and post-SEPSS scores show significant differences in perceived improved ability to assess, assist, and engage in shared goal setting with patients. Learners report developing independence in skills involving care coordination, effective communication, COVID-19 assessment, and referrals. Qualitative data suggests that learners’ confidence towards CCTM improved and they felt positive about their ability to apply these skills into practice.

Conclusion/applications: This novel curriculum provides explicit education and training in ambulatory care that is often missing in pre-licensure nursing education, particularly skills in CCTM. Findings suggest that learners better understand the roles of ambulatory care nurses due to the opportunities provided in the curriculum and they are more confident about their ability to provide nursing care in ambulatory care settings. Future work will be directed toward augmenting this curriculum with additional learners and collecting a more comprehensive evaluation of their knowledge, skills, and attitudes.

Purpose: To promote patient safety by providing clear guidelines and tools for educating patients, physicians, and advanced practice providers while successfully managing out-patient’s chronic “non-cancer” pain.

Description: A pain management registry was created for an ambulatory care family practice physician group that consists of 8 physicians and two advanced practice providers. The physicians, staff, and nurse leader registered approximately 400 patients within the first year, and successfully executed a multifaceted program that resulted in a 31% reduction of opioid prescriptions. The goal was for patients to visit the clinic on a specialized pain clinic day that was designed to focus on opioid assessment and education. In addition, the patient and provider completed a mandatory pain agreement, drug screen, functional assessment score, calculation of MME’s (morphine milligram equivalent), and scheduling of a return office visit to see the physician every 3 months; the prescriptions are given at these appointments only (including naloxone prescription when indicated). A positive correlation identified with this trial has been that the patients do not call the office for narcotic refill requests, which in turn increases patient compliance and staff perception of increased safety.

The creation of this registry allows ambulatory care nurses to be more proactive and efficient in how patients are managed while enhancing education, collaboration among health care teams, active engagement in clinical workflow development, and support of the development of safe treatment options. Clinical team members quickly check patients’ needs against evidence-based clinical guidelines, including incorporation of the state PMP (prescription monitoring program), to assess for any potential diversion of opioids; preparation includes development of a urine drug screen protocol, and coordination with the psychology department to have LCSWs (licensed clinical social worker) onsite to counsel appropriate patients.

The registry includes the name and MRN (medical record number) of the patient, name and dose of the prescription, last prescription fill date, date of last urine drug screen, status of naloxone prescription, PMP information, chosen pharmacy, date of last office visit, status of pain agreement, functional assessment scores, MME, and diagnosis. PCPs (primary care providers) were provided with education regarding the opioid weaning process as well as education regarding critical conversations with patients related to the risks of opioids and education regarding the use of the functional assessment tool, calculation of MMEs, and documentation requirements.

Evaluation/outcomes: First-year outcomes have shown patient/physician collaboration, which resulted in a 31% reduction in the amount of chronic opioid prescriptions. This includes identified diversions and physician/patient collaboration to wean. Embracing the evidence-based guidelines, the health care team is able to meet the needs of this specialized patient population, which promote positive outcomes, and enhance patient and staff safety.
References
1. Kral, Lee A., (2006). Opioid Tapering Safely Discontinuing Opioid Analgesics. Retrieved from http://paincommunity.org/blog/...

Purpose: The objective was to assess the current nurse-led safety monitoring program, propose process improvements, and implement necessary changes.

Description: In 2017, a nurse-led safety monitoring program was established within the rheumatology clinic at a large academic medical center to closely monitor patients prescribed chronic opioids. The monitoring program highlighted the role of the nurse as a vigilant guardian and was aligned with institutional and national recommendations for monitoring of patients receiving chronic opioid prescriptions.

The development of the safety monitoring program improved the documentation of recommended screenings and assessments. In early 2019, documentation of the screenings and assessments decreased. Additionally, gaps in the current monitoring program were identified.

A workgroup was formed, comprised of two RNs, an LPN and a clinical nurse specialist. A baseline assessment was completed of the current safety monitoring program to identify areas for improvement. The identified areas for improvement were prioritized and a specific measurable goal for each identified need was determined. Benchmarking assisted with formulating proposals for process improvement.

The workgroup collaborated with multidisciplinary members within the division to garner support for workflows that extended beyond nursing. After approval of process improvements, a comprehensive education session was conducted with the nursing team to review the safety monitoring program. The monitoring program was also reviewed at a division meeting to ensure all team members were aware of and on board with changes.

Evaluation/outcome: Improvements to the established safety monitoring program included identification and implementation of a multidisciplinary escalation process to use when safety concerns arise. Additionally, a standard multidisciplinary process was established for patients requiring a urine screen prior to prescription pick-up.

Metrics showed improved results for documentation of all recommended education, screenings, and assessments. The annual RN education visit and the controlled substance agreement were completed for an additional 34% and 17%, respectively, of the total patients on chronic opioids. Annual urine drug screen completion rates increased an additional 50%. The state prescription monitoring program was reviewed 55% more frequently. A multidisciplinary opioid plan of care was established for an additional 35% of the total patients on chronic opioids.

A comprehensive, nurse-led safety monitoring program for patients prescribed chronic opioids assists with adherence to institutional and national safety recommendations. Continuous improvement of such a program supports continued success.

References
1. Costello, M. (2015). Prescription opioid analgesics: Promoting patient safety with better patient education. American Journal of Nursing, 115(11), 50-56.
2. Dowell, D., Haegerich, R., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. Retrieved from https://www.cdc.gov/mmwr/
3. volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2F
4. www.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

In late 2010, one organization recognized the need to serve their growing patient population beyond clinic hours. As a result, the call center (CC) began in 2011 with three full-time (FT) RNs, including a manager to provide much-needed round-the-clock support to cancer patients and caregivers. Several factors drove changes that, now nine years later, allowed the CC to solidify its role as an integral player in the delivery of care at the organization.

When determining education and competency needs, the call center had been operating under the umbrella of the outpatient nursing department, and as such, annual competencies, ongoing education, and the RN orientation program are dictated by the same requirements as RNs working in the clinic, oncology treatment teams, same-day surgical unit, and the specialty teams. However, telephone triage is a very specialized and challenging form of nursing. Education and competency requirements are very different than other nursing practices.

A team of nurses working in the CC developed an ongoing education plan for existing CC RNs, an onboarding process for new stakeholders, and an annual competency plan that incorporated JCAHO requirements.

Method: The project team analyzed CC metrics, key performance goals, staffing patterns, recruitment activities, and onboarding process and surveyed CC RNs. Based on these findings, the project team identified specific practice areas where improvement was needed, including the development of an effective onboarding process for RNs new to not only the call center, but telehealth nursing.

Findings
• Comprehensive orientation and onboarding process needed for new CC RNs
• Annual nursing competency program for CC RNs that also included JCAHO requirements
• Need for specialized telemedicine/telenursing ongoing education for CC RNs that is grounded in evidence-based practice
• Explore staff development opportunities for CC RNs

Implementation
• Journal club specific to telenursing and telehealth operations
• Development of comprehensive orientation program during onboarding process, designed by CC stakeholders based on educational need and past experience
• Development of annual competency program specific to telenursing and telehealth needs and operations
• Development of specialized courses addressing topics that pertain to telenursing and telehealth that are available to all CC RNs through Healthstream, our education provider.
• Excellent clinical resources and education opportunities made available to all stakeholders including free continuing education, tuition reimbursement, and reimbursement for pursuit of specialty certification

Results
• Improved job satisfaction for current CC RNs
• Increased retention of new CC RNs
• Improvement in patient safety and satisfaction ratings

References
1. Mangold, K., Tyler, B., Velez, L., & Clark, C. (2018). Peer-Review Competency Assessment Engages Staff and Influences Patient Outcomes. The Journal of Continuing Education in Nursing, 49(3), 119-126. doi:10.3928/00220124-20180219-06
2. Mataxen, P. A., & Webb, L. D. (2019). Telehealth nursing. Nursing, 49(4), 11-13. doi:10.1097/01.nurse.0000553272.16933.4b
3. Rutenberg, C., Greenberg, M. E., & American Academy of Ambulatory Care Nursing. (2012). The Art and Science of Telephone Triage: How to Practice Nursing Over the Phone.
4. Standards. (2019). Retrieved from https://www.jointcommission.or...
5. Van Houwelingen, C. T., Moerman, A. H., Ettema, R. G., Kort, H. S., & Ten Cate, O. (2016). Competencies required for nursing telehealth activities: A Delphi-study. Nurse Education Today, 39, 50-62. doi:10.1016/j.nedt.2015.12.025

Problem: The ambulatory care management team at Carilion Clinic lacked the necessary tools to demonstrate readmission risk reduction for patients undergoing care transitions.

Purpose: This quality improvement project aimed to determine if implementing a real-time workflow management system which supported the prioritization, intervention tracking, and coordination of transitions of care, would result in readmission avoidance through risk reduction.

Background: The accountable care strategies team implemented an electronic transition tracking tool (T3), as one aspect of Carilion’s readmission reduction program.

Evidence from the literature: Approximately 20% of Medicare beneficiaries are readmitted within 30 days following hospital- or facility-based care (Fischer et al., 2014). Many health systems across the country have developed strategies to reduce hospital readmissions after the passage of the Patient Protection and Affordable Care Act and its requirement for the implementation of a hospital readmissions reduction program (ACA, 2010). While there are a variety of readmission risk stratification tools used to identify patients, the predictive performance of these tools, according to Kansagara et al., (2011), has been marginal due in part to the complex factors contributing to a readmission. These researchers recommend incorporating a larger data set to include social determinants of health (Kansagara et al., 2011). Patient’s social determinants have a significant impact on their readmission risk, thus ambulatory care programs which address these factors are essential (Calvillo-King et al., 2013).

EBP question: 1) Is there an impact on readmission for a patient who undergoes risk reduction strategies by a nurse using an automated patient prioritization tool with predictive interventions?

Methods: The ambulatory care management team uses a relationship-based model, partnering with patients in self-care which is grounded in Dorothea Orem’s theory of self-care (Petiprin, 2016). The aim is to support personal agency in the achievement of effective self-management. A tool was needed to replace a manual system which could identify and prioritize at risk patients and track interventions and readmissions. A real-time data system was implemented called T3; it aggregates patients from both in and out of network hospitals. T3 also ingests information from Jvion, a machine-learning platform that provides a readmission risk scoring and associated interventions. A dashboard displays patients and their risk scores, along with recommended interventions. Ambulatory care nurses working remotely select a patient for outreach, review machine-recommended interventions, and use nursing judgement for a patient-centric approach. Readmissions prevented are recorded using specific criteria.

Outcomes: On average. 2200 patients were managed each month and received risk reduction interventions. Over 11 months, 212 patients had a readmission prevented. With the average cost of a hospital stay at $11,200.00, these 212 prevented readmissions would have cost well over 2 million dollars. Most importantly, the team saved patients from sustaining additional health complications due to a readmission.

Implications for practice: Health systems focusing on readmission reduction need to consider using a predictive tool which incorporates social determinants of health and recommends targeted interventions. Prioritizing discharged patients, managing and tracking interventions, and recording readmissions prevented by ambulatory care nurses will demonstrate improved quality of care transitions.

Description: Telehealth services are drastically expanding throughout the health care sector, driven by the need for cost savings, more convenient and accessible care, and more recently during the COVID-19 pandemic, safer options for patients to connect with their health care providers. Despite the rapid growth, there are questions about the quality and effectiveness of virtual visits, especially as it relates to antibiotic prescribing. Some estimates show that 30% of all antibiotics prescribed in the outpatient setting are inappropriate. However, it is still largely unclear what differences, if any, exist in antibiotic stewardship and prescribing practices between telehealth and in-person visits.

Methods and analysis: In this literature review antibiotic prescribing practices for upper respiratory infections between telehealth and in-person visits are compared and contrasted. The results of seven retrospective research articles published within the last five years were included in the review, accounting for more than one million patient visits for acute upper respiratory infections.

Results: Results were mixed on whether antibiotic utilization and prescribing practices differed between telehealth and in-person visits. There was evidence to suggest that telehealth visits may result in either increased or decreased antibiotic prescribing, depending on institution type (private versus teaching), provider years since graduation, practice culture, patient expectation, type of infection, and provider specialty. However, one study suggested that virtual visits may adhere more closely to antibiotic prescribing guidelines. In certain infections, like sinusitis, there was either no significant difference in antibiotic prescribing or decreased antibiotic utilization in the virtual setting. This review adds to the body of evidence that antibiotic utilization may be less related to visit setting and more related to outside factors and helps demonstrate health care can be delivered virtually without compromising patient care.

Learning outcome and conclusion: Evidence is inconclusive as to whether antibiotic prescribing rates for patients presenting with acute upper respiratory infection differ when comparing in-person versus telehealth visits. Technology will continue to alter the way providers deliver health care. Therefore, further research is needed to assess patient outcomes and quality of care in virtual versus in-person settings as telehealth continues to expand offering patients more convenient and accessible health care.

Purpose: The purpose of this project was to develop and assess a simulation toolkit for teaching key ambulatory care nursing competencies to pre-licensure nursing students.

Background: As health care needs in the community grow in complexity, there is an increased need for nurses to deliver high quality care in ambulatory care settings. Yet, nursing students are not adequately trained for this specialty role. As part of an academic-practice partnership (APP) between a major university school of nursing and a regional health care organization, an ambulatory care (AC) simulation toolkit was designed to enhance clinical reasoning and skills unique to ambulatory care settings.

Methods: The APP curriculum team developed simulations addressing: 1) annual wellness visits (AWV), 2) EHR inbox management, 3) telephone triage, 4) chronic illness self-management, and 5) psychological first aid. Clinical content experts reviewed all simulations, which were then revised accordingly. Simulations were implemented with BSN students in Autumn 2020 via video conferencing due to COVID-19. Students completed online evaluations on which they rated their attainment of the learning objectives and responded to items from the simulation evaluation tool-modified (SET-M). On the SET-M, respondents rate the effectiveness of prebriefing, the scenario, and debriefing. All items were rated “strongly agree,” “somewhat agree,” or “do not agree.” The study procedures were approved by an institutional review board.

Results: A total of 79 students completed the AWV, EHR inbox management, and telephone triage simulations to date, of which 44-53% completing the evaluations. Over 90% of the students responded “strongly agree” or “somewhat agree” on their ability to meet the 5 learning objectives for each of the simulations. “Strongly agree” was endorsed by ≥75% of students on all except 3 objectives: understanding top-of-scope RN practice in the AWV simulation (68%), and ability to document care in the EHR inbox (57%) and telephone triage (69%) simulations. On the SET-M, students responded “strongly agree” to the items in each domain. Pre-briefing (2 items): AWV, 68-76%; EHR inbox, 77-80%; telephone triage, 83-95%. Scenario (11 items): AWV, 38-76%; EHR inbox, 51-83%; telephone triage, 60-91%. Debriefing: AWV, 84-92%; EHR inbox, 88-91%; telephone triage, 95-100%.

Conclusions and implications: Results indicate that overall, the AC simulation toolkit was designed in such a way that the learning objectives were met, except for three objectives addressing top-of-scope RN practice and documentation. Future work will focus on strengthening the simulations to meet these objectives. The SET-M responses supported the effectiveness of the prebriefing for the EHR inbox and telephone triage simulations, and debriefing of all 3 simulations. The prebriefing of the AWV will be revised, and the scenarios of all 3 simulations will be revised according to the specific SET-M items that were rated poorly, which differed between the scenarios. Future research will explore the translation of the competencies addressed in these simulations to in-person clinical settings. The AC simulation toolkit demonstrates promise in filling a crucial gap in addressing the nation’s health by providing practical RN training that is specific to ambulatory care.

Background of the problem: Transitions can greatly impact hospital readmission risk when there is a gap in communication. An absence of a standard process to facilitate communication between the skilled nursing facility (SNF) and patient care team leads to gaps in information related to patient’s plan of care, medication management and continuity of care.

Literature review: Communication tools, care coordination, and collaboration between SNFs and patient care team support patient continuity of care and reduces patient risk for 30-day readmission. Care coordination of patient transitions reduces readmissions. Health information technology tools facilitate communication and reduce patient risk.

Objective/purpose: Establishing a standardized process of communication between SNF and primary care providers fosters partnerships and reduces fragmentation of patient care with SNF transitions. Utilizing a health information technology (HIT) web- based tool, CarePort, facilitates communication of patient information and supports care coordination of patient care that occurs with SNF transitions.

Methods: Established partnerships and implemented standardized process of communication with SNFs to support communication of SNF patient transition information. Standardized communication of SNF patient transitions using templates and technology tools. Standardized communication tools, with use of templates, to support patient SNF transition care between the SNF setting and primary care practice team members, population health medical assistant (PHMAs), HIT team, and primary care coordinators. Implemented standardized process of communication with SNF and primary care team, with the use of CarePort portal, for monitoring SNF patient transitions and outcomes. Establish and increase collaborative partnerships with SNF care team to support communication of transition patient information, using standardized documentation, technology, and CarePort portal. Utilize technology to collect, store, monitor, track, and communicate patient information and data related to patient SNF transition status. Utilize CarePort technology portal tool to support communication of SNF patient transitions.

Outcomes: Improvement of communication between SNF and primary care team members in 6-month time period. Increase # of SNF telephone contacts from primary care team. Increase # of SNF partnerships formed through CarePort portal. Reduced 30-day hospital readmissions of SNF discharged patients with implementation of standardized communication tools. Standardization of communication tools and collaborative partnerships supports communication of SNF patient transition information and bridges transitions from SNF setting and primary care. Communication tools and collaborative relationships facilitate and support care coordination of patient transition care with SNF and primary care settings.

Conclusion/implications for nursing practice: Developing standard processes of communication between SNF and primary care team members supports patient transition care and decreases readmissions. Establishing collaborative relationships and utilizing technology supports continuity of patient care across the continuum. Standardized communication tools support communication of patient information between SNF and primary care practices and foster team collaboration. 

Background: The use of case review is a well-established teaching tool in nursing education, however there is little literature discussing case review to enhance motivational interviewing (MI) skills and professional development for nurses. Case review can provide dedicated time in a risk-free, structured environment to practice and promote skill development. This exercise can translate to real-time techniques for patient care. Historically, the department focused on MI skill development in a different format that was viewed as largely ineffective for team member development. A workgroup was convened to address these needs through a performance improvement project.

Methods: Advocate Aurora Health Care employs a group of RN care coordinators to work with a high-risk patient population with complex health needs. MI is a key component in working with these patients and developing patient-specific goals. While MI is a key component, it is also frequently identified as a continued learning need for team members. Historically, the department utilized a mixed method approach for MI skill development and difficult case review. Annual learning needs assessment results from the team concluded that this approach was not meeting the needs for a large portion of the team; 70% of team members responded neutral or negatively that the historical MI case review process enhanced critical thinking and skills. The workgroup addressed the gaps identified in the learning needs assessment and conducted a performance improvement project to develop the new case review process. Nurses identified and addressed key areas in the new process: needing time for case review, incorporating an educational focus, providing structured tool to present case, and supporting a risk-free environment to discuss cases. The workgroup created a focused approach centered around an evidence-based tool, the Wisconsin Star method, to help investigate patient factors and social determinants of health. The workgroup also developed a standardized template to present the case. Topics for case review were determined and prioritized utilizing the learning needs assessment results. The case review presentation incorporates education on the topic, a patient case for discussion, small group discussions to develop MI questions and techniques, and input from a primary care provider. Addition of an advanced practice nurse to aid in facilitating discussion and skill development has enhanced the case review. Debriefing occurs at the large group level to incorporate idea sharing. Team members leave with key phrases or techniques to use with similar patients.

Results: Post-implementation data was overwhelmingly positive, a 271% increase in team member’s perception that the revised case review process enhanced critical thinking and skills. Results of the project demonstrated that team members felt that the case review process was a safe environment to share thoughts and ideas, enhanced critical thinking skills, provided techniques to use in patient care, and kept MI in the forefront of the work. This case review model provides a framework for incorporating case review into professional nursing practice to enhance critical thinking skills and MI techniques.