Objective: In this presentation, we describe how we created and implemented an undergraduate educational experience around full RN collaboration in primary care visits (Funk & Davis, 2015, Sinsky, Jersak, & Hopkins, 2021). Specifically, we used telemedicine to train pre-licensure nursing students to practice to the full scope of license in the primary care setting.

Background: During the COVID-19 pandemic, several clinical sites shut down in-person services, resulting in a critical shortage of clinical placements for schools of nursing. To address this challenge, a pre-licensure nursing program in a Southeastern state collaborated with a small non-profit, community-based clinic to design an innovative approach using the RN co-visit model on a telemedicine platform, while giving nursing students real-life clinical experience.

In the RN co-visit model (Funk & Davis, 2015), an RN performs an initial assessment on a patient with an acute illness before engaging a provider and follows with post-visit follow-up In other literature, this concept has been called advanced team-based care (a-TBC) (Sinsky, Jersak, & Hopkins, 2021) with many of the same elements applied to telehealth.

Methods: Using the RN co-visit concept, nursing students, in groups of two under the supervision of the RN preceptor, who was also course faculty, reviewed the medical records for their assigned patients before the visit. At the appointment time, they connected with the patient via an approved telemedicine platform with video and multi-user capacity. They performed subjective assessment, including a history of present illness, past medical/surgical history, review of system, and any other pertinent issues brought up by the patient before texting the provider that they were ready.

When the provider logged on to the platform, the students reported their findings under the RN preceptor’s supervision and with the patient’s presence on video. The provider then conducted objective assessment under the limitation of the virtual environment, established the diagnosis and treatment and left the call, leaving the students and the RN preceptor to provide patient education, answer patient questions, assist the patient with resources if needed, and close out the visit.

In each visit, students rotated the roles of primary interviewer or scribe (making notes of the encounter). The RN preceptor/faculty provided students with feedback, assisted them in writing a SOAP (subjective, objective, assessment, plan) note, and entered the note into the electronic health record. The visit generally took between 20-30 minutes.

Outcomes: Students overwhelmingly reported satisfaction and improved confidence in several areas such as communication, assessment, critical-thinking skills, and patient education. The clinical practice also reported satisfaction with the partnership because the providers could see more patients with the flip visit model while improving patient's access to care during the COVID pandemic. Patients also reported satisfaction as they could spend more time with a trusted person: the nurse.

Conclusion: Using RN co-visit model and telemedicine in primary care to train pre-licensure nursing students is an innovative approach to training students in full-scope practice of nurses in primary care and improving patient access.

Purpose: The quality improvement (QI) project aimed to evaluate the impact of conducting telephone triages (tele-triage) during the COVID-19 pandemic and reflect on the outcomes of these interventions on the COVID-19 pandemic to improve the care of patients during a potential future crisis.

Background/significance: The novel coronavirus, known as COVID-19, was declared a public health emergency by the World Health Organization (WHO, 2020) in March of 2020. According to the Center for Disease Control and Prevention (CDC, 2020), the COVID-19 virus has a higher transmission rate when compared to the influenza virus. COVID-19 affects the geriatric population, young adults, and pediatrics with and without any past medical history. In New York City, many hospitals faced challenges maintaining continuity of care during the "shut down" caused by the pandemic. As a result, the role of registered nurses (RNs) and advanced practice registered nurses (APRNs) assumed even greater importance in the continuity of care. In response to the call for a multidimensional approach to ensuring the community served continues to receive seamless and holistic primary and episodic care, the centralized clinical telephone center (CCTC) evolved, for many, into the first contact point for those patients served by the hospital organization. The CCTC comprises RNs and APRNs who deliver primary and episodic triage services using a 100% technological platform. The goal of CCTC is to reduce health disparities, provide timely access to care, and link those patients with the world's best healthcare services. CCTC continues to be on the front lines battling the effects of the COVID-19 pandemic within the community.

Method: This QI project adopted the plan, do, check, and act cycle.

Conclusion: A total of 8112 patients received tele-triage interventions by the RNs of the CCTC, 7,745 patients received tele-triage interventions and episodic telemedicine interventions by the APRNs of the CCTC within the first month of the pandemic. Patients received timely care due to the CCTC's commitment to providing high-quality intervention while allowing for the hospital to focus on critical care and urgent need patients. The providing of these services also proved significant in the deterrence of community spread of the COVID-19 virus.

Implications: CCTC’s APRNs and RNs play a vital role throughout the COVID-19 pandemic. CCTC's tele-triage interventions maintained and, in some cases, increased patient's access to healthcare. CCTC's APRNs managed many patients’ chronic conditions and chronic and episodic medications, thus reducing emergency department visits within an already stressed hospital system. CCTC RN/APRN tele-triage services allowed for focusing internal hospital resources on patients with critical needs. Managing patients at home proved significant in preventing community spread. Telemedicine is challenging, particularly with patients who lack access to technology. Thus, the need for outreach and educational programs to enhance telemedicine availability is necessary, particularly to a vulnerable population.

The purpose of creating telehealth scenarios and the implementation of COVID-19 training was to prepare undergraduate nursing students for the future of primary healthcare and the delivery of that care using telehealth modalities and COVID simulators. Students were provided the opportunity to engage in the following simulation activities:
• Assessing a client using telehealth communication techniques
• Utilizing communication strategies to overcome client barriers to encourage participation and responses during telehealth encounters
•    Identify outcomes for an individualized plan of care for a telehealth client
•    Develop active listening skills during a telehealth encounter with a client
•    Practicing of the use of correct nasal swabbing for the collection of COVID-19 screenings
•    Assessing lung sounds of a COVID-19 client

Students in groups of 4-8 completed four stations that included: telehealth patient intake, patient education, COVID-19 testing, and a patient admission with risk factors of COVID-19.

Students were provided patient demographics for the telehealth encounter. Additionally, students were given CDC guidelines for COVID-19, education points for quarantine and stay-at-home guidelines, and a telehealth algorithm to assist as a telehealth nurse. By completion of the scenario each student was able to:
•    Interview a client via telehealth
•    Assess signs and symptoms of a client via telehealth
•    Implement COVID-19 algorithm via telehealth
•    Educate the client about the signs and symptoms of COVID-19, quarantine guidelines, and when to call provider
•    Demonstrate correct testing on the COVID-19 simulator

By the completion of high-fidelity simulation students were able to:
•    Recognize signs and symptoms of acute infectious respiratory illness
•    Perform a primary assessment of a client with signs and symptoms of an acute respiratory illness
•    Practice interdisciplinary team collaboration and safety
•    Apply appropriate PPE standards
•    Communicate with the interdisciplinary team using SBAR.

Survey results for the telehealth scenarios (N=72) indicated that post-scenarios, the majority of nursing students were:
•    Comfortable to very comfortable: using telehealth technology, assessing clients using telehealth communication techniques, identifying outcomes for an individualized plan of care, and using strategies to overcome client barriers to participate and respond during telehealth encounters. Moreover, the students indicated they can now effectively engage in telehealth encounters as a future practicing nurse.

Survey results for the training related to the use of the COVID-19 simulators (N=47) indicated post-scenarios/training, the majority of nursing students were:
•    Comfortable to very comfortable: performing nasal swabbing for the collection of COVID-19 screenings, and the assessing of lung sounds of a COVID-19 client.

Nursing education needs to embrace the use of technology in the preparation of students for the current and future delivery of primary healthcare. By the utilization of telehealth scenarios and COVID-19 simulators, nursing students were provided “real-life” application of knowledge and skills in a controlled environment. The delivery of nursing education has rapidly changed over time. The current pandemic has accelerated these changes in terms of using technology with a focus on primary healthcare. In order to continue to meet the challenges of preparing holistic healthcare providers, innovative learning strategies and technological modalities will need to be embraced.

1) Identify at least two methods used to develop and deliver a virtual onboarding/orientation curriculum.
2) Discuss the use of virtual platforms to onboard staff remotely.

Over the recent years, much focus has been placed on updating onboarding/orientation programs to increase proficiencies and innovation while maintaining patient safety and quality of care (Kennedy, 2014). Amid the pandemic and the startup of new COVID patient care programs, these changes were forced to occur at a pace no one ever could have imagined.

One large healthcare organization in the Midwest developed three multidisciplinary programs to provide care across the continuum for adult patients testing positive for COVID-19 who were well enough to remain at home with outpatient telehealth follow-up. Each program provided a different level of care based on patient acuity. Nurses from varying backgrounds, specialties, and years of experience were assigned to support these programs. This prompted the need to update and accelerate onboarding/orientation practices to reflect the ever-changing pandemic response.

Curriculums were developed using the organization’s tiered skills acquisition model (TSAM™). Initially, onboarding/orientations were streamlined to include face-to-face classes while adhering to Centers for Disease Control (CDC) recommendations of masking and social distancing, along with virtual onboarding/orientation and preceptorship. Because changes to workflows and processes were frequently evolving, a web-based site was created to share real-time education and resources to support nursing teams.

As surges in the pandemic occurred, the need to onboard/orientate nurses working remotely increased, resulting in the need to convert onboarding/orientation into an asynchronous curriculum, combining virtual classes, self-directed learning, and remote precepting. This poster presentation will provide nurse educators with ideas on how to rapidly transform onboarding/orientation utilizing technology and developing asynchronous curriculums to meet the needs of preceptees and preceptors.

References
1) Joswiak, M.E. (2018). Transforming orientation through a tiered skills acquisition model. Journal for Nurses in Professional Development, 34(3), 118-122. doi: 10.1097/NND.0000000000000439

2) Kennedy, J.M., Nichols, A.A., Halamek, L.P., Arafeh, J.M. (2012). Nursing Department Orientation: Are We Missing the Mark? Journal for Nurses in Staff Development, 28(1), 24-26. doi: 10.1097/NND.0b013e318240a6f3

As technologies and telemedicine soar, our academic healthcare institution has adopted several advanced technologies including high- and low-fidelity simulations, self-guided electronic learning modules, and webinars into clinical orientation to supplement current classroom learning. Beyond the classroom, this initial structured orientation program does not capture the continued professional development needs of a triage nurse as they transition into practice.

Historically, smaller ambulatory care clinics hire a single nurse and have limited in-person training opportunities once they begin the new triage role. A shadow opportunity with a triage nurse in a like-minded clinic for a few days occurs, but continued mentoring has primarily been physician guided. This forces the new nurse to independently manage their own learning and role development. Compounding this problem is the lack of support and isolation that the single nurse-run clinics encounter when not partnered with a nurse colleague’s experience in similar triage role. This evidence-based practice project provided new triage nurses a virtual preceptor utilizing current telehealth technologies during the first 90 days of their transition into practice. The model utilized a performance and perception self-evaluation tool (PPOET) to objectively measure feelings of success, confidence, and clinical performance in their new role. The PPOET included 13 items focused on the knowledge, skills, and attitude of the triage nurse, each on a 1-5 Likert scale with a possible total score of 60. In addition, productivity in managing inbox messages was compared at 30-60 and 90 days to that clinic’s monthly average.

Three new triage nurses received the virtual orientation and completed all study procedures. Five nurses were hired during the study period who did not meet inclusion criteria for virtual precepting and completed PPOET evaluations. Data was collected at three key evaluation points during the new hires’ orientation: 30-60-90 days. There were no significant differences [rating PPOET scores > 3] between 1) orientee and preceptor in the virtual program or 2) participants having virtual orientation and those not having virtual orientation. There was a significant difference in mean percentage of messages completed at 60 days with participants having virtual orientation completing 68.9%, and participants not having virtual orientation completing 79.6% (P=.038). However virtual orientees had the greatest percentage of improvement during the period between 30 and 60 days.

Although the small sample size was without statistical power, the virtual precepting model was a positive experience for the participants entering the single nurse clinics. Virtual preceptors’ and their orientees’ PPOET scores aligned in their evaluation of triage performance and progression in the role. Although virtual participants had a slower progression in completing inbox messages, especially around the 60-day point, all nurses in both groups equalized by the 90-day mark.

Virtual precepting may offer a viable option for support and success of a newly hired nurse working in remote areas who would otherwise be required to self-educate on their role expectations. The goal would be to expand this format of orientation to non-academic areas that may have fewer resources to successfully orient a new nurse into their role.

Learning outcome: Increased knowledge of a model for preparing nursing students to care for patient populations using telehealth technologies.

Purpose: This project provided telehealth education to enhance nursing students’ knowledge and understanding of how to address patients’ healthcare needs remotely and develop plans of care. With changes in the delivery of healthcare due to a global pandemic, federal COVID grant funds were obtained to purchase new telehealth equipment, train nursing faculty, and implement telehealth technology into AASN/BSN curriculum. The purpose of this education was to prepare students to respond to COVID-19 by enhancing their readiness to utilize telehealth technologies.

Description: Telehealth/COVID education was developed by the simulation/IPE coordinator in collaboration with nursing faculty. It was offered across two campuses, in three courses among two pre-licensure nursing programs. The education was delivered using flipped classroom, virtual and/or in-person simulation. Learning objectives included demonstration of collaborative practice as well as identifying the economical, legal, and ethical influences in healthcare delivery using a telehealth platform. Students completed an online educational module, telehealth equipment training and simulation or flipped classroom activity. Telehealth knowledge was assessed before and after participation. The virtual simulation (1 hour) focused on COVID screening using an artificial intelligence driven simulation platform. The flipped classroom (1.5 hours) and in-person simulation (2 hours) focused on telehealth nursing practice where students utilized telehealth technologies with a standardized patient to perform assessment, collaborate with an interdisciplinary team, provide patient education, and develop a plan of care to meet the patient’s needs.

Evaluation/outcome: Learning objectives were achieved: 120 pre-licensure nursing students gained telehealth experience and applied new knowledge and skills to deliver patient-centered care using telehealth technology.

A validated tool (SET-M), was used to evaluate BSN students’ attitudes, preparedness and confidence levels regarding the pre-briefing, simulation scenario, and debriefing sections following each activity. Analyses focused on the percentage of students who selected “strongly agree” for each of the survey items. In general, the in-person telehealth simulation had higher results (64% to 91% strongly agreed to items on the scenario section) compared to the virtual simulation (39% to 61%). The virtual telehealth simulation platform appeared less effective in the application of knowledge and skills across all categories. The highest scoring category identified in the virtual simulation was preparedness to respond to changes in patients’ conditions (61%). Students reported low confidence in feeling empowered to make clinical decisions (39%). For the in-person simulation, the highest scoring category among third-year students was teaching patients about their illness and interventions (91%) and among second-year students was practicing clinical decision-making skills (79%). Students reported low confidence in their nursing assessment skills and feeling empowered to make clinical decisions (64%).

By utilizing the nursing process and telehealth technology, students were prepared to respond to COVID-19 and develop plans of care to address patients’ needs remotely. These simulation activities were beneficial in preparing students for what they will encounter in the future of patient-centered care. This can serve as a model to other nursing programs’ for developing education on telehealth technology.

Background: Improving access to care and limiting unnecessary exposure to COVID-19 during a pandemic by creating and implementing a COVID-19 hotline for the community.

Patients will be able to call 24 hours a day, 7 days a week for information, medical advice, testing, and vaccination relating to coronavirus.

Methods: Data was collected from a single telehealth triage nursing department for one year. Information collected included number of incoming COVID calls and number of incoming calls for all lines.

Results: Over 30% increase in calls directed to the RN telehealth triage team minimizing community exposure to COVID and improving access to care during a pandemic.

Conclusions: Improved access to care during a pandemic. 41, 347 same-day telehealth COVID-19 appointments with COVID-19 providers were completed. 19, 064 COVID-19 patients were managed by the telehealth triage nurses. 504 patients enrolled and monitored in the hospital in the home program beginning April 30, 2020, during after-hours, weekends, and holidays.

In this new age of healthcare, the hour of the day should not impact the quality of care provided to patients. During the middle of the night, patients are often unsure of the severity of their symptoms and seek assistance from urgent care centers, emergency departments (ED) or on-call providers. Due to these limited options, patients are often forced to over-utilize the aforementioned resources, which in turn can place a strain on emergency services. It can also lead to an unnecessary financial burden for the patient. Alternatively, if a patient chooses to forego care, there is a risk for unfavorable outcomes. At one large academic medical institution, telephone triage nurses have been helping guide patients to the appropriate disposition and provide standardized care advice as a best practice for several years. However, this support has not been available to patients after five PM. Previously non-clinically trained call center staff would take patient calls after clinic operations ceased and would page on-call providers for medical advice. Unfortunately, this did not provide immediate access for patients to talk to a licensed healthcare provider about their symptoms, which often delayed patient care.

While utilizing the Iowa evidence-based practice (EBP) as a framework, a root cause analysis (RCA) was identified by the institution as a trigger issue and opportunity to improve patient care. Thus, the after-hours triage program (AHTP) was born. The goal of the program is for RNs to triage patient calls after clinic hours, while using evidence-based decision support tools (DST). Since these nurses came from varying backgrounds without ambulatory care telephone triage experience, they also have providers as a resource if they are uncertain on a disposition or if questions arise outside of their scope of practice.

Before program implementation, the telephone triage educator initially met with the hospital admissions team to discuss launching the AHTPs. The teams collaborated with local and national content experts to help with program development. Logistics of the program included defining hours, staffing, workflows, staff education, and determining departmental priority for initial launch. Training included the new triage nurses shadowing other experienced ambulatory care nurses performing telephone triage in different specialty areas. During implementation, the group decided to target primary care clinics first due to large call volume and variety of symptom-based calls. So far, the AHTP has received 113 calls from the general internal medicine (GIM) clinic since the launch date of October 2021. Positive feedback on nurse triage protocol utilization and documentation was provided during a follow-up call with GIM clinic providers. Due to the success of the program pilot in GIM, the family medicine (FM) clinic was added in November. The goal is to eventually roll out the program to all ambulatory care clinics at the institution. Implications from this project could include a future EBP project around analyzing reason for call from non-clinical call center staff and compare that to reason for call and disposition that the nurse determined after speaking with the patient.

Background: During a global pandemic, the need for a rapid switch to telemedicine was indicated. Having important clinical information documented and technical support prior to the appointment is essential to facilitate a more comprehensive and efficient virtual visit. To help meet these objectives, we implemented a phone call to the patient the day prior to obtain important clinical information and ensure they were prepared for the scheduled virtual visit. However, only 40% of virtual visits were successfully completed as originally scheduled. Both patients and providers were frustrated with the inefficiency and inaccuracy of scheduled virtual visits.

Significance of the problem/literature to support the project: Large health systems face challenges with how to enroll a large population of patients into the required telehealth program, how to engage staff in the expansion of telemedicine, and how to create measurable outcomes (Ellimottil et al., 2018). Only 33% of our patients had the proper access needed for a successful telemedicine visit prior to their appointment time. This barrier forces providers to spend time troubleshooting technical challenges during their appointment instead of focusing on the clinical needs of the patient. Kruse et al. (2018) also noted that technology specific barriers are the biggest challenge in the adoption of telemedicine.

Intervention: To combat these challenges, a pilot model for real time virtual triage with one pediatric specialty division was developed. Health information management team partnered to coordinate direct access in enrolling patients into the preferred telehealth program at the point of scheduling. Instead of obtaining the clinical information the day prior via phone call, a nurse joins the virtual visit on the telemedicine platform 5 minutes prior to the scheduled appointment time. The nurse works through any technical difficulties and obtains the clinical information necessary for visit. This process gives a better patient and provider experience by offering assistance with technical difficulties in real time. This also creates an experience similar to that of an in person visit where important clinical information is obtained and documented prior to provider visit.

Outcome measures: A successful telemedicine visit is defined as a patient enrolled in preferred telemedicine platform prior to visit, clinical information obtained and documented prior to appointment time, and technology working properly in order to complete visit at the scheduled time. Prior to implementation of pilot program only 60% telemedicine visits were successful. After implementation successful telemedicine visits were improved to >90%.

Implications for nursing practice: This real-time patient interaction provides an experience closer to that of an in person visit. This model allows the team to support the patient and obtain the vital information prior to seeing the provider. The partnership to enroll patients in the preferred platform, a consistent team working through the technical difficulties, and improved patient/provider experience makes this virtual triage experience a success.

Background: To ensure efficient and effective care for our rising and high-risk patients, ambulatory care services conducted an analysis of current case management (CM) and direct care registered nurse (RN) services. The analysis revealed primary care CMs and RNs did not work to top of licensure, RN resources were not equitable distributed between sites, and significant variation in services at sites with RNs was found. Leaders also noted RNs who reported to a non-clinical supervisor, which contributed to professional isolation and job dissatisfaction. In response to these findings, executive leadership recommended restructuring CM and direct care nursing services in a centralized model.

Objectives: The purpose of this QI project was to align, standardize, and scale nursing services across all primary care practices in the integrated healthcare system. Services included transitions care management (TCM), HEDIS gap closure, chronic care management (CCM), and RN-led Medicare annual wellness visits (AWV).

Methods: Over an 18-month period, a steering committee of nursing, operational, and physician leaders worked to re-design the structure of CM and direct care nursing services. The committee considered the current workforce analysis, current nursing job descriptions, talent profiles, practice needs, population health needs, patient education gaps, and gaps in nursing care for low and rising risk patient that were not appropriate to be addressed by care managers. The new model centralized nursing services into regional hubs and RNs were assigned a group of practices to support. Assignments were based on geographical location, previous relationship with the RN, provider full time equivalents, patient empanelment, and population needs.

Results: As a result of this initiative TCM call and appointment rates, AWV rates, HEDIS gap closure, STARS, and RN member of the team (MOT) engagement scores improved. TCM call rates increased from 55.7% in December 2018 to 80.1% in September 2021 and TCM hospital follow-up appointment (HFA) rates increased from 23% in 2018 to 50.9% in September 2021, generating 3 million dollars in net revenue. STARs performance for a large Medicare Advantage (MA) population improved from 3.39 in 2018 to 4.6 in 2020. In addition to improvement in STARs scores for this MA population, emergency department (ED) utilization and readmission rates also declined. ED utilization fell from 500/1000 in 2018 to 449/1000 in 2020, and readmissions rates fell from 14.8% in 2018 to 13.5% in 2020. RNs completed over 350 AWV in 2020 and 419 September 2021 year to date. Lastly, RN MOT engagement scores for CM RNs and ICMs saw a 20% increase from 2019 to 2020.

Conclusion: A clear vision and mission is critical for RNs to successfully engage in meaningful CM, TCM, and population health work in a value-based care setting. By aligning primary care RN and CM services under RN leadership and uniting the direct care and CM teams it set the foundation for implementation of evidence-based workflows and programs to improve patient outcomes through shared goals and workflows in a primary care setting.