Purpose/significance: The incidence of patients with multiple complex chronic conditions is rising.1 Patients with chronic conditions often need additional support to identify and understand personal barriers, engage in healthy lifestyle choices for physical and mental health, manage symptoms, and navigate the health care system. In our family practice care team panel, 58% of patients are over 60 years of age. Providers have limited time to spend with patients. Collaboration with the RN care coordinator bridges that gap through understanding a patient’s capacity to care for themselves in regard to resources, support systems, and burdens of illness and treatment. Chronic care management (CCM) and the utilization of the Instrument for patient capacity assessment (ICAN) tool enhance the RN care coordinator’s ability to understand the needs and concerns of the patient. It is imperative to consider the distinct challenges that a patient faces in order to provide individualized care for patients with chronic conditions. The ICAN tool focuses on the patient’s life situation and the potential burdens of treatment. Identification of burdens provides insight into the patient’s challenges and helps the RN care coordinator formulate a contextualized plan of care.2
Methods: Parameters for inclusion: CCM is offered to patients with two or more chronic conditions expected to last twelve months or until the death of the patient. All patients in the CCM program will complete the ICAN tool at initial enrollment and then at all subsequent visits with the RN care coordinator.
Results/evaluation: A retrospective review of patient self-assessed burdens will be done at enrollment and then at each subsequent visit over a period of one year. Data will be analyzed by number and type of burdens, chronic conditions, age, and gender as well as trends over time while patients are enrolled in CCM.
Implications for practice/learning outcome: Connecting with patients; establishing trusting relationships; meeting them where they are at; and understanding patients’ needs, barriers, and values is advantageous to improving patient self-management and health care outcomes.3
1. Leppin, A.L, Montori, V.M & Gionfriddo, M.R. (2015). Minimally disruptive medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare, 3(1), 50 -63.
2. Boehmer, K.R., Hargraves, I.G., Allen, S.V. et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res 16, 514 (2016). https://doi.org/10.1186/s12913-016-1742-6
3. Vanderboom, C.E., Thackery, N. L., & Rhudy, L. M., (2015). Key factors in patient-centered care. Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18-24. https://doi.org/10.1016/j.apnr.2014.03.004
Purpose: To understand the experiences of front-line nurses during the COVID-19 outbreak in Hubei and investigate their views on the role of ambulatory care in the management of COVID-19 and future infectious disease outbreaks.
Background: The emergence of the novel coronavirus disease (COVID-19) continues to stretch the capacity of health care systems worldwide. High hospitalization rates for infected patients have put immense strain on health care workers who tirelessly exert themselves to deliver quality inpatient care amidst critical resources shortages. Exploring their experiences may identify ways in which ambulatory health care can be incorporated into infection control and prevention responses and ease the pressure on hospital resources during future pandemics.
Methods: Purposive, convenience, and snowball sampling were used to recruit 60 registered nurses who provided inpatient care during the COVID-19 outbreak in Hubei. Semi-structured interviews were conducted. Participants were asked to share their work experiences during the pandemic, including challenges faced in patient care, related coping strategies, and suggested improvements for future pandemic responses. Interviews were audio recorded and transcribed verbatim. Resulting data was coded and analyzed thematically according to Braun and Clarke’s (2006) framework.
Results: Participants reported multiple challenges in their experiences of delivering patient care during the COVID-19 outbreak. Due to high caseloads, nurses worked lengthier shifts and took on additional responsibilities in order to make up for shortages in hospital staff, leading to an increase in psychological and physical distress. Support came in the form of fever clinics which reduced nurses’ burden by screening patients for COVID-19 in the community and freeing up valuable hospital resources. Suggestions to improve future epidemic responses and prevent the overburdening of hospital staff included the installation of additional fever clinics and the delivery of reliable public health education in primary care settings, which may raise awareness on infection prevention and control measures and potentially lower overall infection rates.
Conclusions: Nurses in hospital settings have been overstretched due to an unprecedented surge in patients requiring hospitalization. Psychological and physical stress were frequently reported, with a potential reduction in the quality of inpatient care. To protect and reduce strain on hospital staff, ambulatory health care may be explored as a solution to increase community capacity in responding to future infectious disease outbreaks, thus allowing hospital resources to be directed towards the most serious patients and further optimizing pandemic control efforts.
Purpose: Digital communication is rapidly evolving in community care practices. With 85% of our primary care paneled patients utilizing portal accounts, patient online portal messages to team pools and prescription refill requests increased 272% over a five-year period. Nursing and allied health staff support the practice with episodic patient care in addition to tasks such as prescription refills, pre-visit work, patient education, and reviewing and completing messages in message center. Messages were not addressed in a timely manner due to competing priorities. The additional non-visit care and clerical burden required a change to team workflows. an electronic medical assistant (EMA) role was developed to shift messages from nursing and provider in-baskets. The clinical background of an EMA adds value to message review and handling. Initial trial results showed that an EMA was able to manage 82% of patient medical advice requests and 47% of messages to patients.
Description: Results from the EMA trial helped to secure funding for a 12-month pilot to restyle two full-time medical assistants as EMAs. Goals were to reduce message volume downstream by capturing certain message types, increase efficiency and order by routing messages strategically, and have care team members work to their highest scope of practice. Each EMA was assigned to 11 providers. Two new in-baskets were created: one to address patient advice requests and one for prescription refills. In the 2-month training period, EMAs completed direct portal messages and provider requests to call results. A suite of smart phrases was created to provide language and tone consistency when communicating with patients. In addition, EMAs responded to incoming patient calls and assisted with prescription refills. Team member assignments were adjusted on high-volume message days. Data on in-basket total message volumes and number of refill messages for EMAs and providers was collected at pre-pilot, training, and post-implementation intervals.
Evaluation/outcome: Total in-basket message volumes increased for physicians and EMAs from pre-pilot levels to training and post-implementation intervals. However, the number of in-basket messages by user type indicated that physician patient advice messages decreased from 98% pre-pilot to 64% during implementation. Physician refill messages decreased from 100% pre-pilot to 69% during implementation. EMAs managed 28% of patient advice messages during training and maintained at 27% during implementation. EMA refill messages increased from 19% during training to 36% during implementation. EMAs had a sense of ownership, developed competence, and focused on message completion. The smaller feedback loop showed an increase in efficiencies while providing shorter message response times, which increased patient satisfaction. Smart phrases were well received by patients and the practice. The greatest impact to the practice will come from task shifting among remaining nursing and allied health staff. With the EMA managing patient messages, other team members can focus on clinical tasks nearer to the limit of their licensure such as pre-visit planning, wellness services, or procedures. This task shifting has potential for a greater impact to providers than patient message volume reduction alone.
Purpose: The purpose of our contribution is to demonstrate the opportunity for improved patient care and nurse satisfaction by expediting clinical assessments and disposition during quick response (QR) calls.
Description: While rapid response teams (RRT) have been identified as best practice in hospital settings, there is a paucity in the literature regarding emergency medical response in ambulatory care patients, particularly in an outlying, stand-alone clinics with limited staff support (Rojas et al., 2017).
The quick response team (QRT) at this clinic is responsible for reporting to all QR calls within a 300,000 square foot building which encompasses approximately 50,000 square feet of medical space. This clinic is the largest outlying independent ambulatory care clinic within the local network with approximately 22,000 enrolled patients. The QRT consisted of two registered nurses (RN) and was responding in a “ramp up” model. This “ramp up” methodology is described as being nurse-led and does not include a provider responding simultaneously. In contrast, a “ramp down” approach consists of a provider concomitantly responding to all QR calls.
Growing frustration motivated a team of clinic nurses to evaluate nursing staff’s perception of the QRT process and perceived barriers. A layout analysis was completed and demonstrated multiple decision points resulting in time wasted in locating a provider. A similar circumstance was also found in the literature, where it was noted that “awaiting the physician arrival from the ICU further delayed necessary transitions to the ED” (Dechert et al., 2013). We found this “ramp up” phenomenon was also present in our outlying clinic setting where nurses were responding alone. Implementation of a “ramp down” approach in our clinic included executing a “doc of the day” plan where a provider is assigned to respond (with the RNs) to all QR calls for the day. Doc of the day was implemented in October 2019.
Evaluation and outcome: “Time spent” data was collected for all quick response calls 180 days prior (99 calls) and 180 post-implementations (54 calls) of doc of the day. The average time spent on QR calls was 48 minutes prior to “doc of the day” in comparison to 30 minutes post-implementation. Nursing staff surveys were also completed 180 days prior and 150 days post-implementation. In May 2019, 75% of surveyed primary care nurses reported frustration in finding a provider, and 57% of nurses indicated they would hesitate in initiating an intervention without a provider present. These values decreased by 58% and 27%, respectively.
Implementing a “ramp down” approach in responding to emergency situations in an ambulatory care clinic decreased the mean duration of QR calls by 18 minutes over a six-month period. The learning outcome and conclusion is that simultaneous provider response expedites the dispositioning of patients requiring evacuation to a higher level of care, decreasing the potential for poor patient outcomes. This “ramp down” approach and process improvement scenario may be implemented in other similar outpatient settings to improve efficiency, patient safety, and staff satisfaction.
Background: 30 million Americans have diabetes, with an additional 84 million suffering from pre-diabetes. These patients demonstrate a significantly increased risk for heart disease, stroke, renal failure, blindness, and impaired peripheral circulation and neuropathy (CDC.gov, 2019). In the ongoing effort to improve health outcomes while reducing inefficiencies in ambulatory care, this organization has developed a diabetes health professional program (DHPP) to standardize the mechanism for providing patients with the education necessary to prevent progression of the consequences of diabetes without increasing staffing cost.
Methods: The American Association of Diabetes Educators (AADE) offers an online, self-paced diabetes paraprofessional program that provides an advanced body of core knowledge and skills related to diabetes education and management that is geared towards health care professionals. This program was utilized as a basis for the DHPP in this organization. Clinical staff (MAs and LPNs) were nominated by managers to enroll in the program. Care was taken to ensure that nominations were spread across many of the ambulatory care offices to ensure a standardized approach to diabetic education for patients and families across the organization. The DHPP is run by a registered nurse (RN) clinical educator who oversees the students, providing additional mentoring and tutoring as needed as the students learn the material. Once the students complete the program, their successes are celebrated and they immediately begin their work. They choose a taskforce (2019 taskforces include eye exam; foot care; importance of hemoglobin A1C (HA1C); importance of micro-albumin testing; and monitoring blood pressure, nutrition and blood sugars) and work together to develop educational materials and forums for their co-workers, patients, and family members. Materials may include huddle talking points, flyers and bulletin boards for the offices, pamphlets, and short videos for staff and/or patients, etc. The RN clinical educator remains a mentor and works with a dyad physician champion partner; together they provide guidance and final approval on all teaching points, materials, and forums.
Results/outcomes: The major metric for this program is the organizational diabetes bundle compliance score. YTD the score is above target at 78.22 (up from 2018 close of 77.33). Additionally, this program is designed to positively impact employee engagement and patient experience.
Implications for practice: The developed curriculum incorporates chart prep, patient communications, rooming practices, and office staff communications to provide standardized education across ambulatory care setting. This DHPP drives quality outcomes, fosters a positive environment that promotes engagement and professional development among staff, and empowers patients living with diabetes the knowledge required to achieve optimal health outcomes. The cost of the program is about $200 and is covered by many organizations’ continuing education benefit. On average, the program takes two about months to complete with a majority of the work being completed by the students at home.
1. CDC.gov. (2019). Division of diabetes translation at a glance. Retrieved from https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm
Pneumococcal disease is a leading cause of vaccine-preventable illness and death”.1 Pneumococcal vaccines are recommended for patients age 65 and over and high-risk patients, however adherence rates remain low.1 Two pneumococcal vaccines are available for older adults: Pneumococcal conjugate vaccine for adults 65 and older (PCV13/prevnar 13) and pneumococcal polysaccharide vaccine (PPSV23/pneumovax 23).
The nurses at adult primary care, a primary care clinic serving the underinsured, uninsured, and most vulnerable population of Hartford, CT, and surrounding areas, in line with the CDC Healthy People 2020 National Immunization Goals 2 saw the need to increase vaccinations in the ambulatory care setting for patients who were identified with a COPD diagnosis. Approximately 200 patients were identified and placed into four categories: patients with no history of pneumococcal vaccinations, patients who have received/not received PPSV23, patients who have not received PCV13, and patients who have received both PPSV23 and PCV13.
This nurse-driven initiative involved members of the whole team, including medical assistants who called eligible patients that were identified to come to the office for vaccinations during established pneumonia vaccination clinics. Nurses also proactively reviewed provider schedules for patients aged 65 and older who needed PCV13 vaccination. A best practice advisory (BPA) was established in the electronic medical records (EMR) with the support from the Hartford HealthCare (HHC) system support office to alert providers of the patients’ need for the pneumococcal vaccine. Vaccination rates for the population in this pilot increased as a result of this initiative: pneumovax 23 vaccination increased to 89% and prevnar 13 vaccination increased to 77%. In conclusion, the BPA has increased providers awareness to patients’ need for vaccinations in general. Once the BPA proved effective, HHC began using the BPA system wide to increase vaccinations rates. We have also seen an increase in vaccinations rates for TDap, hepatitis A, hepatitis B and influenza.
1. Pennant, K, Costa,J, Fuhlbrigge,A, Sax, P, Szent-Gyorgyi, L, Coblyn, J Desai,S. Improving Influenza and Pneumococcal Vaccination Rates in Ambulatory Specialty Practices. Open Forum Infectious Diseases 2015;1-9.
2. CDC. Healthy People 2020 National Immunization Goals.
Background: In response to the COVID-19 pandemic, our ambulatory care services division (ASD) primary care practices temporarily stopped in office care and adopted virtual visits. The transition to a virtual care model affected the ASD anticoagulation clinics located in the practices. Over 5000 patients needed continued anticoagulation services and monitoring. Approximately 60% of the patients required face-to-face visits.
Objective: The objective was to develop and implement a temporary solution to continue point-of-care testing and encourage patients who were able to adopt remote testing. The team’s top priorities were patient safety and comfort and nurse well-being and confidence, ultimately decreasing fear by providing care that is safe and efficient. ASD anticoagulation leaders needed a solution that would allow the team to continue point-of-care testing, maintain staff safety, and encourage fearful patients to continue international normalized ratio (INR) testing.
Methods: To ensure continuity of care for patients whose care required face-to-face visits, the team stood up seven centralized drive through tent locations and expanded home-testing capabilities. To deliver care in this new model the team took the following steps:
1. Encouraged patients who could enroll in home testing to do so and collaborated with a home-testing company to increase efficiency of enrolling new home-testing patients.
2. Utilized RNs not engaged in care at testing sites to enhance the anticoagulation services virtual team.
3. Established tent testing locations:
• Leadership assigned staff to dedicated tent teams for the duration of the project.
• RNs at tent sites donned proper PPE in accordance with Centers for Disease Control guidelines and our organization’s policy while working at tent sites.
• Tent site teams instructed patients to stay in their vehicles and wear a mask through the entirety of the visit.
• Patients were arrived in the electronic medical record (EMR) for their visits.
• While the patient remained in their vehicle the tent site RNs conducted a COVID-19 screening and completed an anticoagulation assessment.
• Virtually the team completed the visit in the EMR and managed the patient’s dosing.
Results: Warfarin management was successful; enrolled patients’ average time in therapeutic range (TTR) remain unchanged from pre COVID-19 averages. Prior to clinics closing in March 2020, the average TTR was 60.75%. In April and May 2020, the average TTR was 61%. In addition to maintaining TTR performance, the new workflows decreased appointment length of time from 20 minutes to less than 5 minutes. Shorter appointments reduced risk of exposure for patients and the nurses. Home testing also expanded; over 100 patients were transitioned to home testing. Lastly, the new process maintained staff safety; there were no reported cases of RNs exposed or diagnosed with COVD-19.
Conclusion: Our nurses skillfully collaborated to ensure safe, effective, and efficient care. Anticoagulation services temporarily closed 32 clinics for 8 weeks, quickly implementing innovative solutions to continue care for patients who could not receive care virtually. Patients continued to have their POC testing and warfarin therapy monitored, resulting in very little variation in TTR.
This poster serves as complementary material to the rapid fire presentation “Responding to COVID-19: Multidisciplinary Leadership Creating New Care Models in the Face of a Pandemic” presented during session 213 of the 2021 AAACN Annual Conference.
The rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has impacted health care systems across the United States. Emergency departments (ED), intensive care units, hospital wards, and outpatient clinics have seen an unrelenting increase in patient care volumes due COVID-19. Many other factors of this new virus compound the impact of increased volumes including viral spread, safety, personal protective equipment (PPE), and the unknown. This led to a burgeoning need to transform the way we delivered care to patients who were either presenting to the ED with COVID symptoms, identified by serology testing as being COVID (+) and/or calling the health care system.
Under the guidance of the Centers for Disease Control and Prevention guidelines and internal infections disease physicians and nurses, a system-wide response was developed to manage COVID (+) patients safely, effectively, and efficiently while containing the spread of the virus to health care workers. A resource team was gathered, working collaboratively to respond to the need to ultimately provide safe care for our COVID (+) population. The team included an operational support staff, physician, clinical nurse, advance practice leader, and the ambulatory care educator and utilized the A3 methodology for improvement. The group focused on managing patients via outpatient methods to minimize unnecessary contact with health care workers and the general population as well as decrease ED visits.
Two separate care delivery models were created, one virtual and one for in-person encounters. Within the delivery model, key components included staff needed and skill set, training/education, technology requirements, patient access to the care system, care delivery process, personal protective equipment (PPE), and safety. Re-purposing physical space and workflow onsite to minimize COVID transmission was paramount, as well as requiring the virtual team to have a designated workspace with the requisite technology. A dedicated team of redeployed clinical staff worked were precepted in person and/or virtually. Infectious disease training and donning and doffing of PPE was provided by the ambulatory care educator and the infectious disease physician in person and also via on-line and virtual formats.
Analysis of the care delivery system included reconciling data from the scheduling platform and the organization’s data warehouse management reports to determine the number of calls, messages, patients, and number of encounters. A daily dashboard was provided that displayed the total numbers of patients that received care in person or virtually.
From March 27, 2020, and April 3, 2020, through June 15, 2020, the nascent virtual outpatient management clinic (VOMC) and the newly created onsite outpatient acute respiratory clinic (ARC) managed 6,215 calls/encounters and 604 outpatient visits, respectively.
Through multidisciplinary leadership, clinical innovation, and use of the best available evidence, the team created best practices for the transformation of the care delivery and management of primary care patients who were battling COVID-19. The approaches described can provide best practices for leaders in response to newly identified infectious disease and the care delivery models.
Purpose: The purpose of this quality improvement (QI) scholarly project is to describe primary care nurses’ (PCNs) utilization of telehealth in the primary care setting by evaluating a training program for PCNs that supports best practices and promotes efficient care delivery. The sudden onset of the COVID-19 pandemic led to the rapid implementation of telehealth technology in primary care settings, leaving clinicians to quickly adapt essential functions of care delivery with minimal education and training. Telehealth technology provides a cost-effective, efficient alternative for patients to access care from a distance, promoting delivery of the right care, to the right patient, at the right time. Given that telehealth has become a key component of care delivery, understanding PCNs’ perception of telehealth, as well as providing appropriate training, may influence utilization practices in the future. The Learning Objectives are to 1) describe telehealth for primary care delivery, focusing on PCNs and 2) explore PCNs utilization of telehealth to address patient education and integration of telehealth skills and knowledge into practice.
Description: This QI project utilizes a plan-do-study-act framework and will be performed at a non-profit, primary care organization, recognized as a leader in the field of primary care. The project consists of two phases. First, a comparison analysis of PCNs’ telehealth utilization rates, both pre- and post-educational training, will be completed through electronic medical record review to establish baseline and post-implementation criteria. Second, a web-based survey will explore the telehealth practices and program satisfaction among PCNs working in internal medicine for at least one year who participated in a telehealth training program. The survey will be developed and evaluated by a group of expert nurses for content validity, with refinements based on feedback. The final survey will be disseminated through Qualtrics, a web-based program. Descriptive statistics will be used to describe survey results, and free text data will be consolidated into themes regarding suggested recommendations for improving telehealth services.
Evaluation/outcome: This project is currently in progress with expected completion by January 2021. Results will be compiled into an executive summary and professional presentation to be shared among stakeholders consisting of nurses, physicians, and administrative leadership. Results will outline the educational experience and gaps influencing telehealth utilization practices and provide recommendations for future educational and training programs. Through appropriate education and training, PCNs may successfully integrate telehealth practices to positively impact access to care and overall patient outcomes as telehealth care delivery becomes universally available to patients. Better understanding telehealth utilization may serve as a template for other disciplines and care team members across the organization, increasing the value of care to patients.
Purpose: The purpose of this project is to evaluate the effectiveness of an education bundle on increasing patient knowledge and utilization of the portal system by patients seeking care in federally qualified health centers (FQHCs).
Background/significance: Patient utilization of portal systems continues to be low despite widespread availability (Zhao et al., 2017). In 2017, patient self-reported use of portal systems was only 28% in the United States (Grossman et al., 2019). Lack of knowledge, computer skills, and internet access, along with privacy concerns, patient demographics, and lack of provider buy-in, are potential barriers to utilization of portal systems (Zhao et al., 2017). Underserved populations, such as individuals of low socioeconomic status, racial/ethnic minorities, those with chronic illnesses and/or disabilities, and the elderly, often have decreased levels of health literacy and are less likely to use patient portal systems (Grossman et al., 2019). Use of the portal system may lead to increased health literacy and help to overcome some of the barriers to achieving health equity in these populations (Grossman et al., 2019). Prior research on this topic is limited and excludes Spanish-speaking patients. Effective strategies to increase utilization of portal systems in underserved populations are needed and can potentially be addressed with implementation of bundled education interventions.
Methods: To increase patients’ knowledge and use of the portal system, researchers created and implemented an education bundle at two rural FQHCs providing care to underserved populations, in which approximately 16% of the population is best served in a language other than English. The bundle consists of staff/provider in-services, training of a portal resource staff person at each site, instructional videos on the clinics’ website, informational and instructional brochures, and informational flyers posted in patient rooms and at registration. All patient educational materials are in English and Spanish.
To assess effectiveness of the education bundle on increasing use of the portal system, researchers will compare the number of medication refill requests 4 months prior to and 4 months after implementation of the education bundle. Additionally, researchers will review results of an anonymous portal system patient satisfaction survey collected by the clinics during the spring of 2020 and conduct a voluntary follow-up patient satisfaction survey 4 months after implementation of the education bundle. The survey will be available in both English and Spanish.
Results: Data collection and analysis for this project are ongoing and will be completed in January 2021 and included on the poster presentation if invited to participate. Descriptive statistics and independent group tests will be used. Based on the level of measurement for the data analyzed, Chi-square test will be used. General comparisons of the aggregate data percentages will be used to evaluate clinical significance.
Conclusions/implications: This study aims to determine the effectiveness of an education bundle on increasing patient knowledge and use of the portal system. The results can potentially be used to support the continued use of an education bundle to inform patients of portal systems and their functions and increase access for English- and Spanish-speaking patients.