Purpose: To describe an innovative academic clinical coordination model that supports developing academic-practice partnerships, promotes BSN student competency development, and improves patient outcomes in underserved populations.
Description: As part of a 4-year HRSA grant integrating primary care competencies into the BSN curriculum, an academic-practice partnership was formed between a northeast Ohio university-based school of nursing (SoN) and a federally qualified health center (FQHC).
Two senior students were placed with the FQHC wellness team as part of their clinical experience. In collaboration with the FQHC preceptor and improvement officer, a quality improvement initiative (QII) was completed identifying FQHC patients who were at risk for diabetes and hypertension (HTN). The students developed evidence-based screening tools to assess the presence of social, mental health (MH), and medical factors that place a person at risk for developing diabetes and HTN.
Sophomore students were placed at the FQHC to complete COVID-19 outreach activities. This need was discovered through continuous grant staff involvement with the FQHC.
Evaluation/outcome: Using the academic clinical coordination model, the following occurred:
• SoN clinical faculty and sophomore students supported:
o COVID-19 outreach activities including symptom assessment, vaccination scheduling, and self-care/disease prevention strategies.
o Care coordination and transition management (CCTM) competencies of nursing process, advocacy, and support for self-management, respectively.
• The QII diabetes and HTN screening tools:
o flagged the same number of at-risk patients as the automated system.
o identified that 65% of the patients experience food and financial insecurity.
o identified MH factors in 90% of patients with diabetes and 80% of patients with HTN.
o supported development of CCTM competencies of nursing process and population health management.
• Handoff of the QII to incoming senior students, including student huddles related to next steps.
The academic-practice partnership continues to expand through periodic evaluation and planning meetings. In addition to continuing the diabetes and HTN screening QII, sophomore students will be integrated into the QII; senior students will orient the sophomore students to the QII and support coordination of outreach calls, phone screening, and follow-up appointments. Follow-up appointments will be made with senior students for patient education and counseling on self-management and healthy lifestyle options, FQHC dieticians, and primary care or MH providers as indicated by the screening tool. Additional primary care competencies of support for self-management, teamwork and collaboration, and education and engagement of patient and family will be introduced to the nursing students, while continuing to meet the FQHC’s goals of improved patient screening and self-care prior to disease progression in patients at-risk for diabetes and HTN.
Multiple levels of student learners in an FQHC may not be possible due to limited RN staff. To achieve these outcomes, the innovative model of an onsite academic clinical coordinator will be introduced to support student exposure to the primary care setting, competency development, and patient care. Additional measurements are anticipated to evaluate outcomes related to economic feasibility, competency development, and patient outcomes.
The academic clinical coordination model aligns with the 2017 Macy Report, Partners in Transforming Primary Care, promoting faculty and student primary care competence.
Increasing pressure to manage the cost of healthcare has resulted in shifting care towards ambulatory care settings and is driving a focus on cost transparency. There are few nurse staffing to workload models developed for ambulatory care settings, less for multi-specialty clinics. Of the existing models, few have been evaluated against outcomes to understand any impact. This evaluation took place after the AWARD model for nurse staffing to workload was implemented in a multi-specialty clinic at a regional healthcare system in the Midwest. The multi-specialty clinic houses 26 medical and surgical specialty practices. The AWARD model was implemented in two specialty practices in October 2020. Donabedian’s structure-process-outcome (SPO) model was used to evaluate outcomes based on changes to the structure and processes of care provided. The AWARD model defined and quantified the processes, recommended changes in the structure of day-to-day nurse staffing. Cost of care per patient visit, total visits, total nurse performed visits used as structural and process measures, influencing the outcomes of cost of care and access to care. Independent t-tests were used to compare the difference in variables pre- and post-implementation. The SPO model was useful as an evaluation tool, providing a simple framework that is understood by a diverse care team. No statistically significant changes in cost of care, total visits, or nurse visits were observed, though isolating the effect of the model was impossible given the circumstances. Two weeks into the post-implementation period, the multi-specialty clinic paused all non-critical patient visits due to a second surge of the COVID-19 pandemic. Clinic nursing staff was re-allocated to support the inpatient areas. This negatively impacted the ability of the nurse manager to fully utilize the AWARD model to plan daily staffing. The SPO framework could be used for ongoing assessment of nurse staffing performance. Additional variables could be measured giving a more complete picture of the impact of nurse staffing. Going forward there must be continued focus on the outcomes of care and the value of nursing. The primary learning outcomes for this presentation are awareness of the need to quantify the value of nursing and knowledge of one approach to measuring nursing value in the ambulatory care setting.
The purpose of this project was to standardize the practice of ambulatory care nurses relaying abnormal test results to patients, while remaining in their scope of practice, through the development and implementation of protocols and competency training.
It is imperative to patients’ health that they receive test results in a timely, appropriate, and understandable manner. Providers had previously been responsible for relaying abnormal results, but often requested the assistance of nurses to relay results due to provider time constraints. This practice falls outside of the nursing scope of practice. Nursing leadership knew a solution was needed to keep nurses working within their scope, while continuing to support providers and patients. A review of the literature found no evidence-based practice (EBP), articles, or research regarding nurses relaying abnormal test results to patients. The state board of nursing was contacted and advised that there must be policies and protocols in place that include a competency signoff for nurses to relay these results. With no guidance through EBP, nursing leadership followed the guidance from the board of nursing and developed 12 abnormal lab result protocols.
Nursing leadership developed these protocols with information from Up to Date, Mayo Clinic, and the CDC. Protocols were reviewed by an interprofessional group including medical doctors (MD) and nurses. In a joint effort with providers, the medical director created EPIC smart phrases that coincided with each protocol, extracting key points from the protocols and including EPIC smart text options for providers to easily modify to meet specific patients’ needs. Working with this interprofessional team, a workflow was developed allowing providers to review the abnormal lab results with accompanying protocols, and send nurses messages requesting they relay the results using the EPIC smart phrase.
Once the protocols were finalized, competency training for all nurses through simulation phone calls with providers was completed. Messages in TEST patient charts were sent to individual nurses for each lab result being tested for competency. The nurse and provider simulated a phone call with the provider acting as the patient and the nurse calling the patient with the abnormal lab result. The nurse was evaluated utilizing a rubric completed by the provider. Nurses who did not pass the competency were re-educated and repeated the competency.
By utilizing protocols and competency training, nurses can safely and effectively work at the top of their licenses. The development of these protocols has significantly impacted patients, nurses, and providers. Nurses report feeling more confident in their knowledge about these lab results and more equipped to answer patient questions that arise during these calls. Providers and nurses have shared that this has improved the nurse-provider relationship, with nurses feeling more comfortable approaching providers with questions and providers better understanding the nursing scope of practice. Nurses and providers state this comfortability comes from the interactions during the competency training sessions. Through nurses, patients now receive abnormal lab results sooner, and the information the patients receive is standardized and consistent.
Shared governance nursing models emerged in acute care settings over 30 years ago as a method to increase nursing autonomy and professional practice. Hospitals with robust shared governance models report increased nurse retention, decreased costs, and improved patient outcomes. While this model is well established in many hospitals, its existence in the ambulatory care setting is not as mature. Shared governance and professional nursing councils are critical to advancing the role of the ambulatory care nurse.
A professional ambulatory care nursing council structure was developed at a large integrated health system with over 200 physician practices throughout Illinois and Michigan. The organization is split in five large geographic regions, with more than 15 unique markets covering metropolitan communities to rural health offices, primary care, and specialty practices.
Foundational work for this council structure began before the pandemic and through 2020 the importance of nurse engagement in the office became more evident. The charter outlined specific requirements for the council membership as well as how the nursing councils would have bidirectional communication between upper leadership structures and the frontline. Councils were implemented in all five regions with representation of all markets within each region, primary care, pediatrics, other service lines, and specialties. Each regional council was assigned a mentor to support the chair and co-chair with basic council leadership skills, goal writing, and participation. The journey to educate, recruit and start councils reignited in January 2021 with all five regions holding their inaugural council meeting in March 2021.
Early outcomes of council implementation has been the professional networking opportunity connecting ambulatory care nurses from different offices, sometimes hundreds of miles apart. This has allowed the members to share common challenges, align best-practices for quality, and professional mentorship. Future goals of the councils are to increase education and awareness of the role of ambulatory care nursing in quality patient outcomes, advance utilization of nurse clinic in the office, and promote the value of nurse-driven ambulatory care care to patients and families.
Purpose: The objective of the presentation is to describe the structure, the implementation process, and outcomes of a clinical advancement program in the ambulatory care setting. In addition, we will highlight the organizational challenges and lessons learned.
Description: LEAD (lead, excel, and develop) is a system-wide multidisciplinary clinical advancement program that improves clinical practice through local projects and research. Literature illustrates the positive influences of this type of program in the inpatient setting: advancing nursing, improving retention and engagement, and generating better patient outcomes (Hossli, Start, & Murphy, 2018). Internal data collated from LEAD implementation at various inpatient settings throughout our medical system has shown that LEAD advances local and organizational goals, increases nurse engagement, and enhances the patient or staff experience. For participants, LEAD empowers clinicians to identify opportunities to drive change and positively impact relationships, reliability, efficiency, and growth. Upon successfully completing the program, participants receive a compensation bonus.
Through anonymous engagement surveys, ambulatory care nurses at our organization have consistently voiced a concern regarding the lack of career development opportunities and a desire for a clinical advancement program. Hossli, Start, and Murphy (2018) found that this type of program in the ambulatory care setting led to an increase in nurse engagement and an increase in percentage of staff who obtain certification.
In FY22, our organization is implementing LEAD in the ambulatory care setting. In order to be accepted into the program, LEAD projects must fit specific criteria such as aligning with clinic/programmatic goals, collecting measurable data pre-/post-intervention, and staying within the span of control of the clinician. Participants can choose to either lead a project or be a supporting team member of a project. Additionally, each participant is required to complete level-specific training and mid- and end-year presentations within a designated timeframe to be eligible for the compensation bonus. The eligibility criteria reflect the attributes of a nurse and include education, certification, and role-specific requirements.
This presentation will highlight the program’s impact on nurse engagement, retention, and opportunities for professional growth. It will also include an overview of the infrastructure required to manage the program, anticipated direct and indirect costs, and challenges to program success.
Evaluation/outcome: A clinical advancement program for ambulatory care nurses will enhance professional development, improve staff engagement, and recognize clinicians for going above and beyond to advance clinical practice. Benefits to the organization include optimized care delivery, process improvement, and better patient outcomes.
References
1) Hossli, S., Start, R., & Murphy, M. (2018). Implementation and evaluation of an ambulatory care nurse clinical advancement system. Journal of Nursing Economics, 36(3), 149-155.
Purpose: To streamline electronic health record (EHR) documentation to increase efficiency and RN time management.
Background/significance: Historically, RNs spend much of their productive time documenting patient care and interactions. Depending on personal preference and situations, nursing notes can range from short focused to long and detailed. Additionally, variations in documentation compromise the healthcare team by impacting the readability of patient care notes. To provide efficient manual typing and remove variation, many EHR systems have built-in documentation tools also known as “smartpharses/smartlinks,” which auto-populate data and information into a note. “Smartphrases/smartlinks” may be independently developed or customized by the RN to utilize for many note types. Additionally, the “smartpharses/smartlinks” may be shared with other staff members within the EHR system. We discovered that poor use of “smartpharses/smartlinks” across ambulatory care areas resulted in RN spending a disproportionate amount of time between the patient encounter and the documentation of that encounter. Increased use of “smartpharses/smartlinks” will decrease documentation time and remove variation, thus improving efficiencies/productivity. On average, a person of moderate skill types 40 words per minute. The potential for increased RN productivity is substantial.
Method: Baseline reports were created to measure the total manually typed character count and “smartpharses/smartlinks” utilization. Department RNs made “smartpharses/smartlinks” and agreed to utilize them for their standard most-used note types. To monitor progress, reports are reviewed monthly, anticipating increased “smartpharses/smartlinks” usage and decreased manual typing.
Results: After one month (April 2020), the pilot clinic resulted in a 2% increase in “smartpharses/smartlinks” and a decrease in manually typed characters of 5.35%., resulting in a reduction of manual character count by 100,842 characters.
Conclusion: This process is now in five subspecialty clinics, and the preliminary results are encouraging. A full quarter of data will be needed to determine the actual impact.
We are clinical supervisors at the after-hours program of The Children's Hospital of Phila. We are a pediatric telephone triage call center. Our staff consists of RNs and intake representatives who have worked from home locations since 2009. Our nurses triage using Schmitt-Thompson protocols. One of our job responsibilities as clinical supervisors is to orient new hires. Our orientation consisted of classroom time and time spent in the office with a preceptor or in a preceptor's home. In the recent pandemic, we found ourselves having to plan completely virtual orientations. We utilized Skype, Teams, EPIC and Cisco Finesse. Through sharing screens in Skype and Teams and using "supervisor mode" in Cisco Finesse, we were able to successfully orient a nurse and an intake representative virtually. We will continue to use this plan going forward. We learned from these experiences that starting an orientee at home from the beginning allows for more flexibility in scheduling the orientation. As an added benefit, we were able to involve more staff in the "classroom" part of the orientation. This enabled the new hires to meet more of the staff and feel connected to the team from the beginning.
Background: As the complexity of patients in primary care increases and the move towards value-based care payment structures expands, registered nurses (RNs), working to the fullest extent of their licensure and expertise, have been identified as key primary care team partners for improved and cost-effective chronic disease prevention and management, improved quality of the care experiences, and decreased clinician burden and burnout.
Despite powerful drivers to transform primary care settings to include registered nurses there still remains a significant workforce shortage of nurses prepared to fulfill those roles. Baccalaureate nursing programs have historically emphasized acute care; however, primary care transformation demands increased primary care content and experiences so that new RNs are prepared to be full team partners focusing on wellness, providing patient- and family-centered care, population health, care coordination, and data analytics.
Undertaking: Our HRSA nurse education, practice, quality and retention program aims to prepare students and community RNs for transformed primary care roles. We developed 13 online modules that were integrated into baccalaureate programs of study and placed online for access by community RNs free of charge. The content focuses on how foundational nursing knowledge can, and is, applied to primary care. Students and community RNs were awarded digital badges and nursing contact hours upon module completion demonstrating their primary care knowledge to current and future employers. Digital badges are a new form of engaged learning. Additionally, we worked with rural primary care RNs to be prepared to precept students for 150 hours, including preceptor training and the development of standard protocols for RN-led encounters.
Outcomes: Over 2,000+ badges have been awarded to baccalaureate students and community RNs. We have developed relationships with primary care clinics serving rural and underserved populations that have RNs committed to working at the top of their licensure. To support clinics developing these enhanced roles, we delivered 8 online webinars (open to students and community RNs) on the topics of nursing to the top of their licensure such as advanced care planning, transitional care management, chronic care management, and annual wellness visits. The number of nursing students participating in longitudinal primary care clinical placements during their capstone semester has risen from zero to 4,200 hrs.
Conclusions: Nurses have been called out to work to the fullest extent of their licensure as full partners within interprofessional primary care teams. While not new, these roles need to be enhanced and better defined. As healthcare faces the full transformation, there will be more demand for primary care RNs. Therefore, it is imperative that innovative curricula teaching and clinical placements work to prepare RNs for these enhanced roles.
Learning objectives
1) Define nursing roles in transformed primary care and developing nursing content for baccalaureate curriculum.
2) Describe the roles and responsibilities of ‘nurse to the top of their licensure’ including billing for RN-led patient encounters.
3) Describe what a digital badge is and their psychological dimensions.
4) Describe developing clinical sites where nurses work in these enhanced roles.
Present benefits and barriers found during implementation.
Primary care is the base of the U.S. healthcare system and essential in both reducing healthcare disparities and ensuring access to care. RNs are a key to effective primary care, and in recent years, RNs have begun performing complex care such as chronic disease management, preventative care, and care coordination. Few RNs work in primary care offices, and most nursing students do not have a clinical experience in the primary care setting, perpetuating the problem. In the 2017 National Council of State Boards of Nursing Practice Analysis, most newly licensed RNs (74.9%) reported working in hospitals, while only 2.5% of RNs reported working in office settings. These same new RNs reported competence in skills essential for the primary care setting, such as care coordination, patient education, health promotion, chronic disease management, referral processes, and screening assessments.
The HRSA-funded undergraduate primary care and rural education (UPCARE) project is a community-based academic-practice partnership created to bridge primary care and nursing education to enhance services/programs to a rural, medically underserved community. This grant created evidence-based primary care RN preceptor roles tailored to the needs of federally designated rural health clinics (RHCs) in one rural county and then filled these roles with two RNs who work as both full time primary care RNs and BSN student preceptors. Nursing students participated in a practicum in the primary care clinics for 150 hours over four semesters through this primary care-based program. These RNs are the only RNs in primary care in that county and focus on nursing interventions which both increase care access and quality. Students (n = 48) actively participated in patient care alongside the RNs, providing annual wellness visits, care coordination, chronic disease management, telehealth, triage, and home visits. Overwhelmingly, student surveys indicate that this was an overall positive clinical learning experience. Anecdotally, students indicate that through their primary care-based experiences, they have a better understanding of comprehensive patient care and care complexities.
The strategies used to prepare students can easily be adapted for primary care staff professional development. To prepare for home visits, students were instructed in the use of screening tools and assessment to identifying care gaps to share with the interdisciplinary team to contribute to the care plans, and post-visit debriefing was used to enhance learning and future practice. Additionally, staff could benefit from the telehealth primary care simulations that used standardized patients to develop student competence in aspects of the primary care RN role.
This innovative pilot program has been embraced by students, staff, and patients, demonstrating the possibilities of clinical immersion of RN students into primary care environments as well as the strength of a strong RN role in primary care. The UPCARE project has also established community-oriented nursing interventions that are sustainable, flexible, and responsive to community health needs. This is of critical importance to the continued strengthening of primary care in the U.S. health system.
Learning objective: Discuss the importance of partnerships between academia and practice to develop nursing students’ competence in primary care and create a pipeline of new RNs into this setting.
Repeated travel of signals through neuropathways, consistent exercise of large muscle tissue, or the diversion of blood flow through a lesser artery when main routes are blocked result in creation of new patterns, born out of repetition and new necessity. Often, purposeful activity to develop brain, muscle, or even organizational structure is avoided, as commitment to the goal requires overwhelming or unavailable information and resource.
What if the repetition needed for success occurs as a consequence of a different, yet related activity of established value? This may force the enhancement of the muscle, pathway, or desired change as an “unintended” consequence, which, once in place, may be hard to live without.
Registered professional nurses add specific value to ambulatory care practices by impacting quality measures, clinical, organizational, and financial outcomes. Nursing activity has been shown to reduce readmission, promote safety, reduce risk, and improve overall health of communities.
Where ambulatory care centers are overseen by administrative business personnel, clinical roles can be misunderstood and underutilized. Administrative staff are ill-fitted to evaluate clinical competence and supply needed mentorship/education. RNs lack support to advocate for processes that align with professional licensure and responsibilities.
To be effective and practice at highest levels, RN staff need defined oversight, decision-making, and support from expert clinical leaders. However, lacking systems for comparison, coupled with inadequate awareness or research on the impact of nursing services, organizational decision makers have no basis for evaluation.
In our service line of 150 ambulatory care medical and specialty practices, we faced the challenge of a growing RN staff with no mechanism for appropriate recruitment, hiring, and orientation. As complete structural change requires the highest level of organizational commitment over an extended period of time, our small team focused energy on the most critical needs: 1) implementing processes to vet RN candidates by clinical experts and 2) providing structured individualized orientation, created and delivered by qualified nurse educators.
During this presentation, we will describe our beginning in terms of leadership structure, nursing team, hiring, education, and orientation. We will highlight initial interventions, implementation of centralized RN recruitment, evidence-based orientation, and ongoing support for education and professional development. A small qualitative report of RN responses will demonstrate potential impact.
Through tedious repetition of education and messaging, our administrative peers have become appreciative of and reliant on the clinical support we provide. With robust orientation and education programs, we inadvertently forced the aligned concepts of role definition, nursing scope, and breadth of practice.
At the start of the hour, each participant will be asked to supply, one pain point related to nursing education and orientation. Upon conclusion, they will submit an example of an implementation that paved the way for related change. Submissions will be reviewed.
As nurses, using creative strategy to impact patient care and our profession, often with limited resources, has been the backbone and pride of our nursing community. Main objectives are to share our discoveries and inspire participants to consider one creative strategy they can implement toward an important goal.