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.

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.

Purpose: Within our clinical research center, ambulatory care primary clinical research nurses (PCRN) embrace a primary nursing model of care. Our goal is to expand and improve primary nursing in high-volume ambulatory care clinics. This goal is to support nurses in developing positive relationships through continuity of patient care and consistent meaningful interactions with research participants and their families.

Description: A literature review of evidence related to primary nursing using search terms “primary nurse,” “primary nursing,” “primary nursing clinic,” and “primary nursing model” was conducted. Based on our findings, a project plan was developed to identify relevant patient populations that could potentially benefit from our model of care approach. In January 2020, we began to utilize the primary nurse category in the electronic medical record (EMR) system. Working with our IT department, we established a secure method to maintain an active list of primary patient assignments, enabling each PCRN to independently maintain consistency between the EMR system and the secure drive. The nursing progress note in the EMR facilitates communication of pertinent information on primary patients. These improvements promote best practices through education, advancing care coordination and improving transition management when caring for complex research patients. Then COVID-19 happened…

Our original strategy was to implement this plan separately, in each of our three diverse ambulatory care clinics that specialize in conditions within neuro, endocrine, craniofacial and more. The pandemic changed the project dynamics and precipitated the question of “How do we keep our connection to primary nursing, to each other, move forward and socially distance during a decrease in patient census?” We had to adapt and work together, first by establishing WebEx accounts. To adjust, each PCRN selected a patient and created a presentation to include disease, nursing diagnosis, educational needs, and primary nursing impact. Our weekly WebEx presentations led to discussion and expanding our primary nursing process.

Evaluation: Discussion summaries were compiled and organized in SharePoint to include optimizing use of visit time; building team rapport; and maintaining excellent communication regarding education, intervention, and care needs. The team was surveyed to assess the project and determine continued direction. 12 of 15 responded, of which eight wanted to continue with a focus on patient conditions. Comments included “we gained better understanding of the varied processes and practices of our nurse colleagues on other clinics” and concluded that preparation for the project provided time to reflect on “how we can best serve our primary patients.”

Outcomes and implications: This project provided a sense of new community, a connection to nursing and each other during a time of pandemic imposed isolation. Using the WebEx venue provided inclusion, especially of those working from home. Additionally, the experience has inspired topics for future development. This professional learning activity proved to be a positive growth experience for all PCRNs, improving leadership skills, promoting staff integration, and increasing awareness of our unique individual clinic environments.

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.