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.
The authors wish to thank Suzanne Shapiro and Brenda Benik for their assistance with the presentation.
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.
• 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
• 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
• Improved job satisfaction for current CC RNs
• Increased retention of new CC RNs
• Improvement in patient safety and satisfaction ratings
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