Background: The annual wellness visit (AWV) is a benefit established by Medicare for its beneficiaries in 2011. The intent of providing this benefit was to proactively address chronic health conditions and provide preventative strategies to mitigate the development of certain chronic health conditions. This benefit is free to Medicare recipients; however, only 18.8% took advantage of this type of visit with their primary care provider (PCP) nationally.
Historically, the AWV had been completed by the patient’s primary care physician or as a collaborative visit with the PCP and a pharmacist. Medicare allows other clinicians to perform an AWV, including a registered nurse. This allowance provided the foundation for the establishment of a protocol for a RN-led annual wellness visit.
Methods: Three primary care locations were identified to participate in a pilot project which included education on team using established Team STEPPS strategies and developing a workflow for RNs to independently complete an annual wellness visit. Workflows were developed to facilitate the independently performed AWV. Surveys were conducted pre- and post-team building education to assess knowledge base and comfort level related to annual wellness visits. The collection of data includes AWV volumes, volume of additional patient visits scheduled with providers, and completion of preventive testing.
Result: The anticipated results include increased number of AWVs completed at each site, enhanced collaboration between team members, and increased job satisfaction for the RNs in primary care.
Conclusions: Primary care practices continued to be challenged with sufficient access to meet the needs of their patient population. Allowing RNs to independently perform annual wellness visits for eligible Medicare recipients improves access for that population and for other patients in need of primary care services. The primary care RN has the appropriate knowledge and skill set to successfully perform an annual wellness visit and the use of team STEPPS strategies to enhance interprofessional collaboration provides a foundation for transition from a provider only approach to care to a team-based care delivery model. Establishing protocols and workflows to allow the primary care RN to work at top of license supports patient care needs and improves RN job satisfaction.
Despite a high need for registered nurses in the primary/ambulatory health care system, colleges of nursing across the country generally have limited teaching and clinical opportunities for pre-licensure nursing students focused in these care settings. A southeastern college of nursing aimed to change this when they received a Health Resources and Services Administration grant to support an innovative program, “Rebalancing the Curricula to Advance Primary Care Nursing (ReCAP),” that introduces traditional BSN nursing students to additional learning experiences in primary and ambulatory care settings.
In the ReCAP program, BSN students learn about important primary and ambulatory care nursing topics and concepts. Students spend anywhere from 45 to 150 hours in the primary/ambulatory care clinical setting in addition to didactic course requirements. Students are also able to take independent study hours to further study primary care topics of interest. One student taking independent study hours researched the topic of important legal aspects to primary care nursing. This led to the development of a ReCAP program module that participating ReCAP students will study. Modules include learning objectives, select readings, lecture slides, and an associated learning activity based on the learning objectives. This module is appropriate for primary care registered nurses (RNPCs).
The module reveals that in the U.S. primary health care system, RNPCs are seeing an increase in the acuity of patients seeking care, an increasingly diverse population that presents with multiple chronic conditions, an increased focus on pay-for-performance, and the associated increase in documentation requirements, and changes in insurance coverage requirements. There are legal considerations for each of these issues.
With the complexity seen in this environment, primary and ambulatory care leaders find it essential to work within the academic-practice partnership model to adequately prepare nurses for positions in the primary/ambulatory care environment. An important component of this preparation is to ensure that RNPCs are aware of their legal responsibilities.
Special care must be taken by all health care team members to ensure that legal guidelines are considered when delivering and documenting care provided to patients. In the primary/ambulatory care setting, the patient’s holistic care is in part coordinated by registered nurses. The primary care office, a contact point for patients experiencing symptoms and illnesses, is seeing an increase in the use of registered nurses. It is the primary care registered nurses’ (RNPCs) responsibility to assess the patient, plan, and lead care coordination efforts, initiate necessary treatments and referrals, provide education to the patient and their support systems, and document this care. All of these responsibilities fall within the scope of practice for RNPCs and can open the registered nurse up to legal liability if rules, regulations, laws, and standards of practice are violated. As primary care patient acuity continues to climb, the registered nurse in this care setting should know these rules, regulations, laws, and standards to ensure that they are practicing within the appropriate guidelines and scope of practice, particularly related to delegation to non-licensed caregivers in these settings. This poster presentation provides a review of key legal concepts/implications.
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.