Background: Public Health Seattle King County (PHSKC) and Seattle Pacific University (SPU) School of Nursing have partnered to create a training center of excellence for undergraduate baccalaureate nurses who have an interest in providing primary care to medically underserved populations (MUP). This academic-practice partnership is afforded by a 4-year health resources and services administration; nurse education, practice, quality and retention grant awarded to PHSKC in 2018. The project called ambulatory care system supported by education and training (ASSET) is currently in project year four.

Purpose: The purpose of this project is to create a training center of excellence utilizing the dedicated education unit (DEU) model to build student nurse competencies in ambulatory care and public health nursing. This transition to practice experience is designed to foster knowledge, skills, and attitudes to care for MUP in ambulatory care and public health settings. The intended outcome is a highly competitive pool of new graduates prepared for direct entry to ambulatory care and public health specialties.

Methods: PHSKC and SPU implemented a DEU model for nurse education in public health primary care settings. This innovative model allows for senior practicum immersion, called “ASSET fellowship,” in a longitudinal clinical experience where foundational concepts in social determinants of health, trauma-informed care, health equity, social justice, harm reduction, motivational interviewing, and patient-centered care are practiced. Fellows apply these concepts to the nursing process as they manage chronic disease, population health, behavioral health, and substance use disorders. The DEU model provides students with consistent, expert, reflective, and relationship-based mentorship throughout the fellowship.

Progress is monitored through survey data collection with the general self-efficacy (GSE) scale, clinical learning environment, supervision and nurse teacher (CLES-T) scale, seminar training surveys, preceptor evaluation of students, academic-practice partnership evaluation, and a daily student service logs.

Results: The ASSET grant is currently in project year four. Preliminary evaluation data show the following findings.
• DEU students experienced positive self-efficacy in 15 out of 16 GSE metrics compared to non-DEU students.
• CLES-T results suggest better outcome for DEU students in 24 of 34 metrics compared to non-DEU students.
•    The preceptors’ evaluation of students reveals staff value the precepting role and report the fellows greatly contribute to the agency in positive ways.
•    Seminar training surveys consistently show increases in students’ abilities and knowledge related to training topics.
•    The academic-practice partnership evaluation shows increasing collaboration and process development over the first three years of the grant.

Conclusions: To date, the data suggest that this innovative model of academic-practice partnership and DEU training is improving student self-efficacy, skill attainment, and enhancing staff satisfaction.

Implication to nursing practice: Academic-practice partnerships are essential for preparing student nurses for direct entry to ambulatory care and public health practice. The DEU model in a public heath primary care setting prepares nurses to work with MUP grounded in principles of health equity, social justice, and trauma-informed care. Further exploration of the DEU model in ambulatory care is needed to assess efficacy of building nursing competencies, nurse recruitment, retention, and staff satisfaction.

Patient care is not provided by nurses alone, but is provided by an interdisciplinary team with different education levels, training, and practice guidelines. In a large academic medical center with over 70 specialty clinics spread over a large urban area, it was difficult to standardize clinical duties. A foundational guidance document, “Scope of Service for Healthcare Personnel in Ambulatory Care” (SOS), defining the scope of clinical duties for nurses and medical assistants existed. However, the document only represented a small sample of clinic roles in the ambulatory care setting and did not provide comprehensive guidance for leaders and staff.

Due to a wide variety of roles and insufficient resources, a knowledge gap was identified. The gap was measured by the number of questions submitted to the clinical education department by clinic leaders regarding other job roles’ license or certification practice parameters. A group of key stakeholders worked to build upon the foundational document to encompass additional ancillary roles. Thus, a source of truth was created for the clinics to refer to decrease variation of practice to benefit both patients and staff.

Since its inception, the SOS document has grown to include 16 clinical roles and 70 patient care tasks. Any requests for edits to the SOS document are reviewed by clinical nurse educators, ambulatory care practice council (APC), and nurse executives by a shared governance process. The clinical nurse educators assess the request’s consistency with state regulations (if applicable), academic degree plans, certification program requirements, and on-the-job training pathways for each discipline. Best practices in current clinic workflows at the institution, professional organizations, and other large academic medical center ambulatory care practices are reviewed as well. Additionally, experts in each discipline are consulted for role specific evidence-based practices. This resource serves as safeguard for clinic leaders to ensure that staff are practicing appropriately within their role limitations. Abiding by the SOS document’s boundaries can provide protection for the staff’s licenses and certifications while they deliver safe patient care. This resource also provides staff with information required to function at the height of their credentials, therefore increasing staff satisfaction and retention. For easy access, the SOS document is available on the institution’s ambulatory care SharePoint site.

Since the release of the document, the number of questions related to clinical practice has declined, emphasizing its value for clinic leaders. The need for this document is also supported by the number of times it has been accessed on the ambulatory care shared site; the latest version has been viewed 937 times since being published in December 2020. Due to the document’s utility and applicability, institutional research department leaders requested a review of their roles and tasks to create a similar tool for research personnel to reference their practice parameters. This document has proven to be perpetually evolving, as there are several new requests for role additions currently being reviewed and considered. With every update to this document, the facility moves one step closer to optimizing our most valuable resource: amazing clinical staff.

Background: Patient care provided in ambulatory care practices has become increasingly complex over the past decade. This complexity represents both patient characteristics, such as requiring transitions in care from the hospital to the outpatient setting, and complexity of providing care through increasingly more complex insurance processes. Concomitantly, there has been a significant increase in ambulatory care visits over the past decade.

The provision of safe, high-quality ambulatory care requires an interdisciplinary team. As a result of the COVID-19 pandemic, a reorganization of our large academic ambulatory care practices was implemented. Six clinical “pods” were created with implementation of a new nursing leadership model. Prior to this reorganization, there was no clinical nursing leadership present in any of our practices.

Methods: Nursing leaders sought to identify quality metrics that were measurable and which nursing could directly impact. Five metrics were chosen, which included patient experience data as measured through Press Ganey CGCAHPS survey scores, hand hygiene compliance via direct observation, data from near-miss reports and actual patient event reports, call center data including the number of calls and time to answer, and formal educational achievement of nursing staff. Specific methods were implemented to improve each of these metrics. Nurse leaders created domain-specific patient experience teams within each pod. The infection control nurse trained our nurse leaders and staff in direct observation hand hygiene monitoring. High-reliability education, including training on Just Culture and reporting, was provided to all nursing leaders and staff. Reports regarding our call center data were utilized by nursing leadership in order to monitor and deploy nurses as needed to adequately handle nursing-related patient phone calls. Finally, nursing leaders and clinical staff were encouraged and supported by the chief nursing officer to obtain further formal education as we work to prepare towards ambulatory care Magnet certification. These measures were obtained over the course of the first year of this new reorganization.

Results: Improvement in all metrics were revealed with the exception of hand hygiene data. Press Ganey data reached its highest overall score in five years. Reporting near-miss and actual patient events more than doubled. Data obtained regarding nurse call volumes revealed an overall increase in calls to a peak of nearly 16,000 calls in June with simultaneous decreases in abandonment rates. Hand hygiene data was the one metric which revealed a decrease in overall compliance. However, this may represent an overall increase in observations revealing more failure points. More time is required to ascertain the validity of this assumption. Finally, educational achievements of the nursing team included a total of four RNs who completed their BSN, one RN who completed her MSN, and one RN that obtained her PhD.

Discussion: Significant areas of improvement were achieved in four of the five metrics measured. Patient care was enhanced through the implementation of a new nursing leadership model. Ongoing evaluation to monitor for sustained improvement is necessary. Nursing leadership in ambulatory care is crucial to providing high-quality and safe care to an increasingly complex patient population.

In November 2020, during the COVID epidemic, monoclonal antibody infusions such as bamlanivimab were identified as an effective treatment for more severe cases of SARS-CoV-2 and were given emergency use authorization (EUA) from the U.S. Food and Drug Administration (FDA, 2020). At our large academic medical system, ambulatory care nursing leadership was tasked with collaborating with pharmacy services, infection prevention, supply chain management, information resources (IR), facilities, and the Epic training team to open an infusion area that could provide biologic infusion services for actively symptomatic COVID patients meeting the medical criteria for treatment. Thus, the COVID infusion clinic was opened within a space originally created for COVID-19 testing with the help of our COVID readiness team, which included staff from ambulatory care nursing operations and other interprofessional teams listed above.

The goal of the initiative was to provide biologic infusion therapy to patients that were high risk for progressing to severe COVID-19. We aimed to do so in a safe environment that reduced the risks of endangering staff or other healthy patients on campus and to decrease the risk of positive COVID-19 patient admissions via the emergency room. One challenge to accomplish these goals was the need to identify clinical area isolated from common patient and staff access, while also meeting the logistical and engineering specifications of needing a negative pressure space within the existing building. This space was identified and created to accommodate the much-needed monoclonal antibody infusions.

Additional challenges included identifying available support staff for patient scheduling and check-in, as well as to identify available infusion certified and trained RNs to administer the infusions to patients. Coordination of additional tasks included identification of necessary supplies, determining the clinical workflow, creating a scheduling template, and creating a staff schedule template based on 7-day-a-week, 8-hour-a-day operations. Collaboration continued, as education and training needs were identified, including PAPR training for all clinical staff. Additionally, pharmacy and logistics leadership were tasked with ensuring the workflow for drug mixing and delivery coincided with the infusion clinic workflows.

As a result of this initiative, over the last 12 months over 750 SARS-CoV-2 positive patients have received and continue to receive treatment with monoclonal antibody infusions. Due to our focus on infection prevention and safety for patients and staff, we have been able to provide this crucial treatment to a vulnerable patient population without an infection transmission to any of the infusion staff.

Background: Nationwide and in Detroit, Michigan, there has been a need for nurses who practice in community-based primary care teams, and as healthcare moves to the community more and more teams will need RNs working to the full scope of their license. The “PC-Chip in the D” Health Resources and Services Administration (HRSA) nurse education, practice, quality, and retention (NEPQR)-funded grant included four goals, of which one major objective was to collaboratively develop a business model to integrate RNs into community-based primary care. The primary focus for this objective was to assist our FQHCs with a business plan which acknowledged to our partners that having RNs on staff would provide a robust team care approach and enhance their revenue. Early on, we encountered a gap in knowledge related to billing for RN services amongst our FQHC partners. To move this final objective forward, our team developed a collaborative plan with multiple state level partners to enhance our teams’ as well as the FQHC staff’s knowledge in this arena.

Methods: Our grant team researched the topic as well as collaborated with other states and billing experts on billing for RN services in FQHCs. Our partnerships included a network of representatives from Michigan Institute for Care Management Transformation (MICMT), the Michigan Primary Care Association (MPCA), and the Michigan Center for Clinical Systems Improvement (Mi-CCSI) that brainstormed the best way to share information with FQHCs statewide, including information about RN billing in an FQHC environment, application to a particular site, and the nuances of billing to a variety of Medicaid plans and Medicare.

Results: The NEPQR grant team will discuss the modules/webinars that are being developed for a variety of FQHC staff audiences (e.g. chief financial officers, chief executive officers, RNs, information technology staff, etc.). Modules/live seminars are in developments and are being created by MICMT, MPCA, and the NEPQR grant teams. An example of one module is the differentiation of Medicare versus Medicaid billing for RN services in FQHCs within Michigan. Each module or live session will be 1-2 hours long with an ongoing live Q&A document. The teams will also market the projects to a variety of audiences around the state. Once these modules/webinars launch, they will be accessible to everyone free of charge through the MICMT and MPCA websites. The estimated completion date for the modules is February/March 2022.

Conclusions: In the budget-challenged environments of FQHCs and with the demand for RNs to become members of the care team, leadership teams and RNs need to learn how to generate revenue for services delivered. While RNs enhance the team, in a non-profit community-based setting like FQHCs, leaders may continue to utilize a “lower-cost” option if a revenue source cannot be secured or the value of RN care is not demonstrated. These learning sessions we are developing will assist FQHCs to learn how to bill for RN services as well as the best way to incorporate these services into the practice.

Purpose: Our four-year program evaluation of a primary care/public health immersion experience from 55 students and 14 preceptors aims to inform best practices in student-preceptor, urban ambulatory care immersion experiences and increase the practice scope and numbers of BSN graduates who are prepared to work in medically underserved primary care and public health

Background: Our nations’ underserved urban communities face rising costs, aging populations, and declining life expectancies. In response, ambulatory care leaders seek to empower future ambulatory care nurses to meet these rising needs. Two timely reports reinforce this vision, the Future of Nursing 2020-20301 and the National Academies’ “Implementing High Quality Primary Care”2, and both make clear that ambulatory care RNs are vital to improving healthcare outcomes. Relatedly, Morton3 and colleagues argue that gaps exist in undergraduate education, specifically ambulatory care essential content, including social determinants of health (SDOH), health disparities/health equity, cultural competency, community leadership, and the enhanced skills needed for community-based settings. In response to these calls for increasing academic ambulatory care readiness, nursing leaders at our urban federally qualified healthcare center (FQHC), alongside a local health department and another area FQHC, have expanded our long-standing academic partnerships to include BSN student immersive preceptorships at our respective sites.

Methods: Our evaluation design is assessing the effect of the clinical immersion on undergraduate nursing students in our three ambulatory care settings. Our 55 students and 14 preceptor participants completed validated instrument surveys using Qualtrics® before and after the students’150-hour clinical immersion. Qualitative data is collected from preceptor and student focus groups, Typhon© clinical tracking logs, and weekly reflective journals.

Results: Preliminary results will be discussed and compared to national shared measures data. The experiences of preceptors, their clinic leadership, and students provide quantitative data using two validated instruments, the SEPSS-364, measuring self-efficacy in self-management support, and C-LEST5, which measures undergraduate clinical learning environments. Qualitative data from each student-preceptor dyad is interpreted via clinical logs, journals, and preceptor focus groups.

Conclusions: Our data informs ambulatory care and academic leadership on how an ambulatory care setting’s academic-clinical partnership can enhance preceptor competencies and improve undergraduate students’ preparation for work in medically underserved, public health, and primary care settings. Our data add concrete guidance and value, as we seek to enable an optimum future of nursing in ambulatory care.

1) National Academies of Sciences, Engineering, & Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. doi.org/10.17226/25982.
2)    National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. doi.org/10.17226/25983.
3)    Morton, J. L., et al. (2019). New education models for preparing pre-licensure students for community-based practice. Journal of Professional Nursing 35(6):491–498. 4Duprez, V., et al., (2016). The development and psychometric validation of the self-efficacy and performance in self-management support (SEPSS) instrument. Journal of Advanced Nursing, 72(6), 1381-1395. doi:10.1111/jan.12918. 5 Saarikoski, M & Strandell-Laine, C. (2018). The CLES-Scale: An Evaluation Tool for Healthcare Education. 10.1007/978-3-319-63649-8.

Through an academic-practice partnership aligned with the HRSA 18-012, RN in primary care training program, Communicare Health Centers, a federally qualified health center, and the University of the Incarnate Word, successfully implemented an RN-OB high-risk initiative focused on RN practicing independently and collaboratively to improve health outcomes.

Purpose: To design an RN-enhanced practice role at a federally qualified health center (fqhc) focused on high-risk obstetric “value-based” outcomes, specifically gestational diabetes, hypertensive disease, risk of preterm delivery, and chronic conditions during the interpregnancy interval.

Aims: To develop effective clinical processes focused on RN practicing to the extent of Texas Board of Nursing licensure for the delivery of safe, high-quality, evidence-based high-risk obstetric care.

Objectives
1) Discuss the processes used to establish an RN-enhanced role practice at a federally qualified health center (FQHC).
2) Describe the work processes for establishing the RN-enhanced role among the population of high-risk obstetric patients.
3)    Discuss the “value-based” outcomes achieved.

Background: Communicare Health Centers, San Antonio, Texas, FQHC, is the defined academic-practice partner for the University of the Incarnate Word School of Nursing’s HRSA 18-012, RN in primary care training program. The women’s health medical director designed and implemented an OB high-risk initiative aimed at the need for reframing clinic processes to focus on high-quality care and value-based outcomes.

Methods: With the approval of the academic-practice partnership, the RN role was defined and implemented in the women’s health clinics. The RNs work independently and collaboratively with the patients and families using protocols focused on “value-based” care. A referral process within the electronic health record allows the clinic staff and clinicians to notify the RN of potential clients. The RN uses multiple care management techniques to engage the clients in achieving improved health outcomes, i.e., blood pressure monitoring, glucose monitoring, referral to health and wellness coaches and dietitians, and local community resources.

Results: A summary of the results will be presented including the internal “value-based” electronic dashboard, project lesson learned, and practice innovation techniques.

Conclusions: Implementing a high-risk OB program with an FQHC focused on population health framework aligned with roles and responsibilities of RN practicing to the extent of licensure produces reduced healthcare costs and improved health outcomes.

References
1)    American Academy of Ambulatory Care Nursing (AAACN). 2017. American Academy of Ambulatory Care Nursing Position Paper: The role of the registered nurse in ambulatory care. Nursing Economics. 35.1.

Purpose: As healthcare transforms and rapidly expands from inpatient to outpatient sites, the role of nursing continues to expand in ambulatory care settings. Ambulatory care nurse coordinators (NCs) provide coordination and care for patients requiring assistance and support in accessing and managing their healthcare needs. The development and implementation of a clinical ladder program has implications for improving nursing retention and engagement for ambulatory care nurse coordinators. Although the concept and benefits of nursing clinical ladder programs have been documented since the 1970s, little research exists discussing the implementation of such programs for NC roles in ambulatory care.

Description: A large academic health system in Northern California developed and implemented a clinical leadership and career advancement program to recognize and reward the professional excellence of ambulatory care NCs across the enterprise. From 2020 to 2021, this program was built by the ambulatory care nursing department in collaboration with a consulting firm specializing in nursing care optimization and facilitated with the partnership of ambulatory care nursing professional development specialists in the organization. The program’s framework was established utilizing concepts from Patricia Benner’s nursing theory and the American Academy of Ambulatory Care Nursing scope and standards of practice for professional ambulatory care nursing, with the following objectives: acknowledge and enhance NC career development, attract and retain high-quality nursing staff, and create a supportive work environment that values NC growth.

Evaluation/outcome: In September 2021, a total of eight ambulatory care nurse coordinators were successfully promoted in the inaugural cohort of the clinical ladder program. 100% of promoted NCs maintained an American Nurses Credentialing Center-accredited nursing certification, held a bachelor of science in nursing degree or higher, worked as NCs within the organization for a minimum of 12 months and within their clinical specialty for a minimum of three years, and were members of professional nursing organizations. Promoted NCs demonstrated clinical expertise and were significantly involved in professional development and leadership opportunities within the organization, including the ambulatory care shared governance council. Metrics indicating program success include reduced staff turnover and improved staff engagement. The next steps for the ambulatory care nursing department involve the measurement of such staff outcomes to further understand the successes of the program and areas of opportunity. The program is anticipated to mirror the successes of its inpatient counterpart in advancing, promoting, retaining, and engaging ambulatory care nurse coordinators.

References
1) American Academy of Ambulatory Care Nursing, & Murray, C. L. (2017). Scope & Standards of Practice for Professional Ambulatory Care Nursing (9th ed.). American Academy of Ambulatory Care Nursing.
2)    Benner, P. (1982). From Novice To Expert. AJN, American Journal of Nursing, 82(3), 402–407. https://doi.org/10.1097/000004...
3)    Pierson, M. A., Liggett, C., & Moore, K. S. (2010). Twenty Years of Experience with a Clinical Ladder: A Tool for Professional Growth, Evidence-Based Practice, Recruitment, and Retention. The Journal of Continuing Education in Nursing, 41(1), 33–40. https://doi.org/10.3928/002201...

Purpose: The purpose of the pediatric COVID-19 care team (PCCT) was to provide a high level of pediatric care for pediatric patients who tested positive for the SARS-CoV-D (COVID-19) virus at any of the health system’s designated testing sites across the Midwest.

Description: When pediatric COVID-19 positive cases began to rise in early 2020, a small group of providers and nurses volunteered to initiate resources, deliver test results, and educate parents about the COVID-19 virus by telephone. In April 2020, leadership at the institution requested to formalize this team to provide a higher level of telehealth care. This team consisted of physicians and registered nurses (RNs) supported by operations, nursing leadership, and project management teams. The goals of the team were to provide medical support and education to families at home, keeping infected patients away from the clinic and facilitating containment of the virus. The workflows included scheduled calls to patients and families occurring several times throughout the isolation period. Initial calls, conducted by the provider on the team, included an assessment of current symptoms and a review of medical history to inform providers of risk for severe disease. Providers then delegated a follow-up call to the nurses on the team to provide program information, enrollment to the program, and connection to community resources. All subsequent calls during the isolation period were delegated to nurses. With time, chart reviews led the team to create needed workflow changes to efficiently manage local surges in COVID-19 cases, allocating resources to those most at risk for severe disease or most vulnerable due to socioeconomic status. Eventually, the bulk of the work transitioned to pediatric nurses in ambulatory care, centering on isolation and quarantine education and how to best access medical care. Informatics assisted in the development of reporting tools and electronic medical record lists to allow for efficient task management and communication. The use of patient online messaging, including bulk messaging, was optimized for those at minimal risk for complications from COVID-19 infection. In the current state, only those who are non-English speaking, are pregnant, are less than 6 months old, or are potentially eligible for monoclonal antibody therapies will receive a phone call from the PCCT. All others are informed of their test results and isolation information via electronic notification in patient online services or a letter mailed to the home.

Evaluation/outcome: Through ongoing program evaluation, the team was able to match the level of care to the acuity, risk, and socioeconomic status of the patient. Improvements in the workflow significantly reduced the volume of required resources while still meeting the needs of the patients. To date, there have been no adverse events reported related to the telehealth care of pediatric COVID-19 positive patients despite significant and ongoing workflow changes made by the PCCT.

Problem: During the beginning of the novel SARS CoV-2 pandemic there was no standardized way to manage the triage of primary care (PC) patients at UC San Diego Health presenting with COVID-like symptoms. It was imperative the nurse triage leadership team develop an appropriate triage protocol for assessment and disposition of patients including providing access to SARS CoV-2 testing. This protocol would aid in the prevention of our healthcare system becoming overrun, preserve healthcare resources, provide access to testing when medically appropriate, and reduce the spread of disease.

Description of the change: As part of the planning stage, the team created a triage protocol that was based on testing availability and included symptoms criteria. As an interim measure prior to the development of a formal Schmitt and Thompson protocol for COVID-19, the team created an EpicPIC SmartPhrase based on CDC guidelines and physician discretion. The registered nurse would assess the patient and disposition the patient based on acuity (e.g., emergency department, urgent care, and home care advice). If the patient was low acuity, the RN could also place and order for a COVID-19 test at one of the drive-thru facilities. The protocol aligned with the PC physician group priority of keeping patients out of clinics while ensuring access to urgent care if necessary and ensure early detection of COVID-19 positive patients in the community.

Results: After review of the data since May 2020, the overall call volume to PC nurse triage increased 23%. Between October 2020 and March 2021, the COVID protocol (includes adult and pediatric PC patients) was utilized 23% of our total calls. The COVID protocol home care advice increased from 13% to 36%. Aligned with the COVID protocol, no patients were dispositioned to a PC clinic while 44 to 60% were provided home care advice to stay home and complete a COVID test at a UCSDH drive-through location. On average, the percentage of patients who call into the PC nurse triage department and dispositioned to ER is 11%; however, within the COVID protocol, it was decreased to 6%, demonstrating a reduction in the utilization in ER resources.

Implications: The standardization of how nurses assessed, managed, and educated COVID-19 symptoms ultimately reduced the spread of COVID-19 in the community. Overall it reduced the burden to the clinics, protected testing resources, conserved PPE during a national shortage, and preserved terminal cleaning resources.

Sustainability: Integrating Schmitt and Thompson protocol into EHR with precise mapped dispositions and applicable home care advice for any future needs.