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Updated: 03/06/23
Learning objective: Evaluate the development of an ambulatory-care based emergency response team (ERT).
Purpose: The purpose of this quality improvement project was to create an ERT within our clinic to provide the best response possible to our patients during emergency situations.
Background: A code in the lobby, hemorrhaging in a hallway, a myocardial infarction in the parking garage, an unconscious employee at his desk, and another diaphoretic, hypotensive employee slumped over in a locked bathroom. This large Magnet-designated medical specialties clinic experienced all these medical emergencies between 2021-2022. However, because we are in an ambulatory care setting, we are unable to keep a crash cart in our clinic. When these emergencies occurred, we felt unprepared to provide the best response possible to these people. According to the few articles that exist related to ambulatory care rapid response teams (RRTs), success is tied to streamlined communication, consistent processes, and implementing standard operating procedures.
Process: After our first major emergency, we identified the need for an ERT within the medical specialties clinic and an easily transportable bag that we could use to create an emergency response kit (ERK). Knowledgeable in rapid response team activation, institutional policies, clinic guidelines, and resources, the nurse manager led the development of the ERT. We used the plan-do-study-act rapid-cycle change method to help us plan and respond to this change. We planned the standard operating procedures (SOPs) we would use when the next emergency occurred and determined the contents of the emergency response kit and the order in which it would be packed (plan). We piloted the process and bag with each of the following three clinic emergencies, improving SOP consistency with each iteration (do). We met after each emergency to determine how we could streamline our process and communication and identify supplies that were unavailable during the emergency from the ERK (study). We refined the process and added to the contents of the ERK, based on the unexpected needs that arose during these emergencies (act). Nursing team leaders now run codes and other emergencies and instruct other staff when the defibrillator, CPR, suction, or ambulance is needed. Nursing team leaders take turns carrying the emergency response pager every quarter. The nursing team leader who ran the emergency within the clinic is also responsible for calling report to the emergency room when an ambulance is required. We also call surprise practice drills monthly to keep our emergency skills and readiness sharp.
Outcomes: The nursing team leaders meet with the clinic nurse manager bi-monthly to discuss incident reports and use of the emergency response kit. Emergencies are now managed confidently by team leaders and clinic staff. We have experienced two emergencies in the past three months; both were handled effectively and efficiently. We will share our 6-month post-survey results (based on Hermis, et al., 2017 and Hinkle, et al., 2021), final detailed processes, roles of our emergency team, and list and order of contents of our emergency response kit as part of our poster presentation.
Purpose: The purpose of this quality improvement project was to create an ERT within our clinic to provide the best response possible to our patients during emergency situations.
Background: A code in the lobby, hemorrhaging in a hallway, a myocardial infarction in the parking garage, an unconscious employee at his desk, and another diaphoretic, hypotensive employee slumped over in a locked bathroom. This large Magnet-designated medical specialties clinic experienced all these medical emergencies between 2021-2022. However, because we are in an ambulatory care setting, we are unable to keep a crash cart in our clinic. When these emergencies occurred, we felt unprepared to provide the best response possible to these people. According to the few articles that exist related to ambulatory care rapid response teams (RRTs), success is tied to streamlined communication, consistent processes, and implementing standard operating procedures.
Process: After our first major emergency, we identified the need for an ERT within the medical specialties clinic and an easily transportable bag that we could use to create an emergency response kit (ERK). Knowledgeable in rapid response team activation, institutional policies, clinic guidelines, and resources, the nurse manager led the development of the ERT. We used the plan-do-study-act rapid-cycle change method to help us plan and respond to this change. We planned the standard operating procedures (SOPs) we would use when the next emergency occurred and determined the contents of the emergency response kit and the order in which it would be packed (plan). We piloted the process and bag with each of the following three clinic emergencies, improving SOP consistency with each iteration (do). We met after each emergency to determine how we could streamline our process and communication and identify supplies that were unavailable during the emergency from the ERK (study). We refined the process and added to the contents of the ERK, based on the unexpected needs that arose during these emergencies (act). Nursing team leaders now run codes and other emergencies and instruct other staff when the defibrillator, CPR, suction, or ambulance is needed. Nursing team leaders take turns carrying the emergency response pager every quarter. The nursing team leader who ran the emergency within the clinic is also responsible for calling report to the emergency room when an ambulance is required. We also call surprise practice drills monthly to keep our emergency skills and readiness sharp.
Outcomes: The nursing team leaders meet with the clinic nurse manager bi-monthly to discuss incident reports and use of the emergency response kit. Emergencies are now managed confidently by team leaders and clinic staff. We have experienced two emergencies in the past three months; both were handled effectively and efficiently. We will share our 6-month post-survey results (based on Hermis, et al., 2017 and Hinkle, et al., 2021), final detailed processes, roles of our emergency team, and list and order of contents of our emergency response kit as part of our poster presentation.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/01/23
Learning outcomes: Participants will be able to describe a framework for a nurse obstetric intake assessment. Participants can describe how this new obstetric intake assessment coordinates obstetric care.
The care of the pregnant patient in an ambulatory care setting requires coordination amongst the care team. Having a clinic network spread across a large metropolitan area allows patients easy access to obstetric care. Patients typically visit multiple obstetricians at different clinic sites throughout their pregnancy. Standardizing and coordinating patient care is necessary to allow for this collaborative approach. Standardized care incorporates best practices to streamline workflow, facilitate continuity of care, and provide quality care. In the past year, a best-practice team created a standardized obstetric intake assessment for nurses to complete with patients via telehealth to enhance obstetric care coordination.
A best-practice team comprised of nurses, the chief obstetrician, and key members of the electronic health record (EHR) group investigated topics previously covered by clinic sites during the intake assessment, documentation in the EHR, and patient education provided to pregnant patients. The best-practice team used evidence-based research to determine which screenings to conduct and develop standard patient education. Once the content for the obstetric intake assessment was agreed upon by the clinical team, the nurses worked with the EHR group to restructure the documentation. Streamlining the EHR improves the nurses’ efficiency in the obstetric intake appointments and improves adherence to the standardized process the best-practice team developed. Education for the nursing staff was developed and rolled out by the best-practice team nurses. Virtual classes with full demonstration within the EHR were conducted. Resources were posted in an accessible electronic channel and contact points set up for questions.
In the new process, nurses conduct an obstetric intake telehealth appointment with each obstetric patient around ten weeks of pregnancy, documenting the results in the EHR. This appointment begins with creation of a pregnancy episode in the EHR, pregnancy dating, medication reconciliation, and allergy review. Next, a full medical, surgical, family, and obstetric patient history is obtained. Pertinent lab results are reviewed, and pregnancy measurements are entered. Standardized early pregnancy patient education is reviewed with the nurse and sent electronically to the patient immediately following the appointment. Three standard screenings are completed, including the Edinburgh scale, the social determinants of health (SDOH) screen, and genetics screening. By conducting these three important screens during the telehealth appointment, nurses can identify important risk factors early in a patient’s pregnancy and coordinate care to improve outcomes.
Following the roll-out of the new telehealth obstetric intake assessment process, chart audits were conducted to assess compliance with the new process. Standardizing the nurse obstetric intake assessment allows any provider within the organization access to the same baseline information for each obstetric patient. This supports the open access organizational plan, which allows patients to visit any provider in any clinic location while supporting coordinated care.
The care of the pregnant patient in an ambulatory care setting requires coordination amongst the care team. Having a clinic network spread across a large metropolitan area allows patients easy access to obstetric care. Patients typically visit multiple obstetricians at different clinic sites throughout their pregnancy. Standardizing and coordinating patient care is necessary to allow for this collaborative approach. Standardized care incorporates best practices to streamline workflow, facilitate continuity of care, and provide quality care. In the past year, a best-practice team created a standardized obstetric intake assessment for nurses to complete with patients via telehealth to enhance obstetric care coordination.
A best-practice team comprised of nurses, the chief obstetrician, and key members of the electronic health record (EHR) group investigated topics previously covered by clinic sites during the intake assessment, documentation in the EHR, and patient education provided to pregnant patients. The best-practice team used evidence-based research to determine which screenings to conduct and develop standard patient education. Once the content for the obstetric intake assessment was agreed upon by the clinical team, the nurses worked with the EHR group to restructure the documentation. Streamlining the EHR improves the nurses’ efficiency in the obstetric intake appointments and improves adherence to the standardized process the best-practice team developed. Education for the nursing staff was developed and rolled out by the best-practice team nurses. Virtual classes with full demonstration within the EHR were conducted. Resources were posted in an accessible electronic channel and contact points set up for questions.
In the new process, nurses conduct an obstetric intake telehealth appointment with each obstetric patient around ten weeks of pregnancy, documenting the results in the EHR. This appointment begins with creation of a pregnancy episode in the EHR, pregnancy dating, medication reconciliation, and allergy review. Next, a full medical, surgical, family, and obstetric patient history is obtained. Pertinent lab results are reviewed, and pregnancy measurements are entered. Standardized early pregnancy patient education is reviewed with the nurse and sent electronically to the patient immediately following the appointment. Three standard screenings are completed, including the Edinburgh scale, the social determinants of health (SDOH) screen, and genetics screening. By conducting these three important screens during the telehealth appointment, nurses can identify important risk factors early in a patient’s pregnancy and coordinate care to improve outcomes.
Following the roll-out of the new telehealth obstetric intake assessment process, chart audits were conducted to assess compliance with the new process. Standardizing the nurse obstetric intake assessment allows any provider within the organization access to the same baseline information for each obstetric patient. This supports the open access organizational plan, which allows patients to visit any provider in any clinic location while supporting coordinated care.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Erin Brinkley, BSN, RN, CMGT-BC | Sharda Moses, MSN, RN, CNL, AMB-BC | Britt Gnilka, DNP, Director of Clinical Operations Complex Care Solutions, Sentara Medical Group
Updated: 03/14/23
Updated: 03/14/23
Background: The Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare physician fee schedule (PFS) for CCM services furnished to patients with multiple chronic conditions. In 2017, our health system launched a CCM pilot, which was retired within 6 months of implementation due to complicated documentation and billing workflows and poor provider adoption. In 2021 with the release of streamlined electronic medical record (EMR)-based billing and documentation solutions, our system revisited implementation of CCM for our 25,000+ eligible patients.
Objectives: The purpose of this process improvement project (PI) was twofold. Our first objective was to develop, implement, and track CCM services for three distinct markets in Hampton Roads Virginia, Blue Ridge Virginia, and Northeast North Carolina. Our second objective was to create a sustainable and scalable financial model to support continued nursing services in both value-based and traditional fee for services contracts.
Methods: Over a 12-month period the project team comprised of information technology (IT), EMR analysts, billing analysts, nursing leaders, and population health analysts worked to create a streamlined process for provider-based billing (PBB) and non-PBB sites. The team capitalized on the standardized workflows provided by our EMR vendor. Using the out-of-the box solution, the team developed a process in which the RNs utilized a standard visit type in the existing centralized nursing EMR departments to document and bill for CCM services. The new documentation workflows reduced documentation requirement by 50% through elimination of duplicate documentation in two EMR departments. In addition to reducing documentation requirements, the team leveraged new capabilities to automate CCM code selection and charge capture by tracking CCM time spent monthly and complexity in a discreet manner. Lastly, a tableau dashboard was created to track CCM enrollment, billing, and revenue by practice and provider.
Results: In the first nine months of implementation, the centralized nursing teams enrolled 1,055 unique patients in CCM. The 1,055 patients had 4,282 CCM codes charged, resulting in 2,728 work relative value units (wRVUs) and $379,711 in gross revenue. In addition, the case management team saw significant improvements in workflow related to consolidated practice assignments. Based on projected CCM revenue over the next five years, CM (case management) leadership developed a business case and received approval to increase RN full time equivalents by 30%. Based on the current year's revenue projections, CCM revenue will cover 75% of the cost of the additional FTEs. The remaining 25% will be realized through shared savings from reduced medical expense ratios.
Conclusion: As the healthcare landscape continues to move to value-based care, the ability to track and bill nursing work in the ambulatory care setting utilizing traditional billing and wRVU methods alongside value-based outcome measures is critical for sustaining and expanding nursing services. For successful implementation and scaling of CCM programs, documentation and billing workflows need to be automated, streamlined, and discreet.
Objectives: The purpose of this process improvement project (PI) was twofold. Our first objective was to develop, implement, and track CCM services for three distinct markets in Hampton Roads Virginia, Blue Ridge Virginia, and Northeast North Carolina. Our second objective was to create a sustainable and scalable financial model to support continued nursing services in both value-based and traditional fee for services contracts.
Methods: Over a 12-month period the project team comprised of information technology (IT), EMR analysts, billing analysts, nursing leaders, and population health analysts worked to create a streamlined process for provider-based billing (PBB) and non-PBB sites. The team capitalized on the standardized workflows provided by our EMR vendor. Using the out-of-the box solution, the team developed a process in which the RNs utilized a standard visit type in the existing centralized nursing EMR departments to document and bill for CCM services. The new documentation workflows reduced documentation requirement by 50% through elimination of duplicate documentation in two EMR departments. In addition to reducing documentation requirements, the team leveraged new capabilities to automate CCM code selection and charge capture by tracking CCM time spent monthly and complexity in a discreet manner. Lastly, a tableau dashboard was created to track CCM enrollment, billing, and revenue by practice and provider.
Results: In the first nine months of implementation, the centralized nursing teams enrolled 1,055 unique patients in CCM. The 1,055 patients had 4,282 CCM codes charged, resulting in 2,728 work relative value units (wRVUs) and $379,711 in gross revenue. In addition, the case management team saw significant improvements in workflow related to consolidated practice assignments. Based on projected CCM revenue over the next five years, CM (case management) leadership developed a business case and received approval to increase RN full time equivalents by 30%. Based on the current year's revenue projections, CCM revenue will cover 75% of the cost of the additional FTEs. The remaining 25% will be realized through shared savings from reduced medical expense ratios.
Conclusion: As the healthcare landscape continues to move to value-based care, the ability to track and bill nursing work in the ambulatory care setting utilizing traditional billing and wRVU methods alongside value-based outcome measures is critical for sustaining and expanding nursing services. For successful implementation and scaling of CCM programs, documentation and billing workflows need to be automated, streamlined, and discreet.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/14/23
Updated: 03/14/23
Purpose: Care for new ostomy patients is complex and requires a multidisciplinary approach. To facilitate positive patient outcomes, new ostomy patients require collaboration between inpatient and outpatient care teams. This partnership is especially essential during the index hospitalization. Without this approach, poor patient outcomes can result. The Centers for Medicare and Medicaid Studies (CMS) and the National Surgical Quality Improvement Program (NSQIP) have specified colorectal surgery outcomes among the top five specialties for improvement (Fish et al., 2017). In addition, patients with a urostomy require a significant amount of care and education both short-term and long-term (Bearti-Hearn, 2019).
Description: A team of 21 inpatient and outpatient staff collaborated from April 2021 to October 2022 to develop standard operating procedures (SOP) streamlining care of new ostomy patients across the care continuum. The SOP detailed roles and responsibilities of the care team from post-operative days 0-5. Prior to implementation, the team identified that all wound/ostomy/continence (WOC) RNs and RNs on the inpatient complex abdominal surgery unit needed ostomy care education. In addition, an ostomy resource packet was developed. To ensure efforts were patient-centered, a patient-family advisor (PFA) reviewed all materials and provided feedback. The team conducted a 20-week pilot to evaluate outcomes directly influenced by the use of the SOP.
Evaluation/outcome: Data collection included hospital length of stay, readmission data, ED visits, outpatient follow-up compliance, staff competencies, and discharge data. In addition, compliance with the standard work/SOP toolkit was monitored. During a five-month pilot, the interdisciplinary group met biweekly to monitor adherence to the standard operating procedures and tracked quality metrics. 32 patients were included in the pilot. Their average length of stay was 11 days. Nine patients (28%) had ED visits within 90 days of discharge. Same-day add-on appointments decreased for the urostomy patients. Eleven patients readmitted within 90 days of discharge. Seven admissions were ostomy-related. 88% (n=28) of patients had WOC RN appointments after discharge. 72% (n=23) of patients had WOC appointments within 14 days of discharge. A post-hospital survey showed discharged patients referred to the ostomy resource packet at least once. 72% (n=23) of patients received 30-days’ worth of supplies at discharge. Improvements in discharge times was noted for patients with urostomies. All WOC and staff RNs on the inpatient unit completed ostomy training and demonstrated competency. 56% (n=18) of patients experienced home health arrangement issues due to staffing. Since the pilot, 90-day readmission rates and 90-day ED visits have improved for all ostomy populations. There were challenges getting patients to watch ostomy educational videos while inpatient. The team also identified that more work is needed to streamline the outpatient appointment scheduling process.
References
1) Bearti-Hearn, L., Elliott, B. (2019). Urostomy care: A guide for home care clinicians. Home Health Care Now, 37(5), 248-255. https://journals.lww.com/homehealthcarenurseonline/Fulltext/2019/09000/Urostomy_Care__A_Guide_for_Home_Care_Clinicians.2.aspx
2) Fish, D. R., Mancuso, C.A., Garcia-Aguilar, J. E., Lee, S. W., Nash, G. M., Sonoda, T., Charlson, M. E., Temple, L. K. (2017). Readmission after ileostomy creation: Retrospective review of a common and significant event. Annals of Surgery, 265(2), 379-387. https://journals.lww.com/annalsofsurgery/Fulltext/2017/02000/Readmission_After_Ileostomy_Creation_.22.aspx
Description: A team of 21 inpatient and outpatient staff collaborated from April 2021 to October 2022 to develop standard operating procedures (SOP) streamlining care of new ostomy patients across the care continuum. The SOP detailed roles and responsibilities of the care team from post-operative days 0-5. Prior to implementation, the team identified that all wound/ostomy/continence (WOC) RNs and RNs on the inpatient complex abdominal surgery unit needed ostomy care education. In addition, an ostomy resource packet was developed. To ensure efforts were patient-centered, a patient-family advisor (PFA) reviewed all materials and provided feedback. The team conducted a 20-week pilot to evaluate outcomes directly influenced by the use of the SOP.
Evaluation/outcome: Data collection included hospital length of stay, readmission data, ED visits, outpatient follow-up compliance, staff competencies, and discharge data. In addition, compliance with the standard work/SOP toolkit was monitored. During a five-month pilot, the interdisciplinary group met biweekly to monitor adherence to the standard operating procedures and tracked quality metrics. 32 patients were included in the pilot. Their average length of stay was 11 days. Nine patients (28%) had ED visits within 90 days of discharge. Same-day add-on appointments decreased for the urostomy patients. Eleven patients readmitted within 90 days of discharge. Seven admissions were ostomy-related. 88% (n=28) of patients had WOC RN appointments after discharge. 72% (n=23) of patients had WOC appointments within 14 days of discharge. A post-hospital survey showed discharged patients referred to the ostomy resource packet at least once. 72% (n=23) of patients received 30-days’ worth of supplies at discharge. Improvements in discharge times was noted for patients with urostomies. All WOC and staff RNs on the inpatient unit completed ostomy training and demonstrated competency. 56% (n=18) of patients experienced home health arrangement issues due to staffing. Since the pilot, 90-day readmission rates and 90-day ED visits have improved for all ostomy populations. There were challenges getting patients to watch ostomy educational videos while inpatient. The team also identified that more work is needed to streamline the outpatient appointment scheduling process.
References
1) Bearti-Hearn, L., Elliott, B. (2019). Urostomy care: A guide for home care clinicians. Home Health Care Now, 37(5), 248-255. https://journals.lww.com/homehealthcarenurseonline/Fulltext/2019/09000/Urostomy_Care__A_Guide_for_Home_Care_Clinicians.2.aspx
2) Fish, D. R., Mancuso, C.A., Garcia-Aguilar, J. E., Lee, S. W., Nash, G. M., Sonoda, T., Charlson, M. E., Temple, L. K. (2017). Readmission after ileostomy creation: Retrospective review of a common and significant event. Annals of Surgery, 265(2), 379-387. https://journals.lww.com/annalsofsurgery/Fulltext/2017/02000/Readmission_After_Ileostomy_Creation_.22.aspx
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/14/23
Updated: 03/14/23
The occupational health clinic at UT Southwestern Medical Center in Dallas, Texas, manages a patient population of over 18,000 employees and over 12,000 students and teachers from the associated medical school. With a population so large, it is understandable that the occupational health clinic receives at least 80-130 phone calls a day. While managing the struggle of handling a large volume of incoming calls is a burden not unknown to any ambulatory care clinic, the staff in occupational health are pulled between managing their own responsibilities, whether it be onboarding, exposures to pathogens, injury clinic, student health, or COVID tracing, and must also manage incoming phone calls from employees trying to find answers to questions as quickly as possible so that they can return to work.
At the beginning of the fiscal year, there was a 60% abandon rate for incoming calls. Employees who called in would be left lost in the haze of the clinic with an overall feeling of frustration. Occupational health staff were also frustrated and felt unable to manage their own duties and the volume of incoming calls. In order to better assist our employees and our staff in occupational health, we developed a schedule of dedicated phone time. Every staff member responsible for managing incoming calls has a set time to devote to care coordination via incoming calls and nothing else, much like the “med nurse” on the floor who would wear an orange vest when they were doing medication calculations and checks so that they would not be disturbed. Shifts are broken up into an hour of dedicated time, and staff are expected to be accountable by recording their end of shift call numbers, so that data can be collected. They also must provide a reason if they are not able to log on for their dedicated time. In this instance, we are always able to assess for time management educational needs and review techniques if necessary.
Two months into this project, we have seen a substantial increase in calls answered and cases handled. We are now at a 40% abandon rate. Employees in occupational health have responded well to the schedule structure. We have found that, rather than expecting all employees that are responsible for answering incoming calls to log onto the phone all at once and expect equal share of responsibility, we have far better outcomes if we use a schedule of dedicated incoming call care coordination time.
We are not yet at our goal of 92% of incoming calls answered and handled, and have now hit a plateau and, unfortunately, stopped improving our numbers. We will next provide reinforcement education on customer service and time management skills to our employees, so that they can improve their swiftness and efficacy when handling cases and questions via phone calls with the goal that our numbers will continue to increase.
At the beginning of the fiscal year, there was a 60% abandon rate for incoming calls. Employees who called in would be left lost in the haze of the clinic with an overall feeling of frustration. Occupational health staff were also frustrated and felt unable to manage their own duties and the volume of incoming calls. In order to better assist our employees and our staff in occupational health, we developed a schedule of dedicated phone time. Every staff member responsible for managing incoming calls has a set time to devote to care coordination via incoming calls and nothing else, much like the “med nurse” on the floor who would wear an orange vest when they were doing medication calculations and checks so that they would not be disturbed. Shifts are broken up into an hour of dedicated time, and staff are expected to be accountable by recording their end of shift call numbers, so that data can be collected. They also must provide a reason if they are not able to log on for their dedicated time. In this instance, we are always able to assess for time management educational needs and review techniques if necessary.
Two months into this project, we have seen a substantial increase in calls answered and cases handled. We are now at a 40% abandon rate. Employees in occupational health have responded well to the schedule structure. We have found that, rather than expecting all employees that are responsible for answering incoming calls to log onto the phone all at once and expect equal share of responsibility, we have far better outcomes if we use a schedule of dedicated incoming call care coordination time.
We are not yet at our goal of 92% of incoming calls answered and handled, and have now hit a plateau and, unfortunately, stopped improving our numbers. We will next provide reinforcement education on customer service and time management skills to our employees, so that they can improve their swiftness and efficacy when handling cases and questions via phone calls with the goal that our numbers will continue to increase.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/14/23
Updated: 03/14/23
Patients with comorbid conditions such as coronary artery disease, hypertension, hyperlipidemia, and heart failure require the expertise of cardiologists and advanced practice providers to provide complex personalized care. The complexity of these conditions demands medical oversight by the provider and care coordination by the registered nurse in the ambulatory care setting.
Purpose: To evaluate the impact of the implementation of clinical pharmacists in the ambulatory care setting of a large academic heart and vascular institute on the nursing workload associated with medications.
Description: The ambulatory care nurses were surveyed to understand the workload associated with medications. The nurses reported spending 10-20 hours per week with patients on medication counseling, addressed an average of 50 messages per week related to medication questions from patients, and completed approximately ten medication prior authorizations per week with payors. The nurses reported inadequate resources to meet the demand of the insurance authorizations and reported having no supportive resources available from pharmacy staff. Therefore, two clinical pharmacists were added to the ambulatory care clinical staff to assist nurses and providers with the high demand for medication-related work. After nine months of implementation in general cardiology and heart failure clinical specialties, the nurses and providers were surveyed post-implementation.
Evaluation/outcome: Post-implementation of clinical pharmacists in the ambulatory care setting, the nurses stated that they had gained time in their day for other clinical work due to a decrease in medication insurance authorizations, a reduction in message basket volume, and an increase in pharmacist-assisted medication counseling. Additionally, the providers reported that medication adherence, affordability, and patient access to medications had greatly improved.
Purpose: To evaluate the impact of the implementation of clinical pharmacists in the ambulatory care setting of a large academic heart and vascular institute on the nursing workload associated with medications.
Description: The ambulatory care nurses were surveyed to understand the workload associated with medications. The nurses reported spending 10-20 hours per week with patients on medication counseling, addressed an average of 50 messages per week related to medication questions from patients, and completed approximately ten medication prior authorizations per week with payors. The nurses reported inadequate resources to meet the demand of the insurance authorizations and reported having no supportive resources available from pharmacy staff. Therefore, two clinical pharmacists were added to the ambulatory care clinical staff to assist nurses and providers with the high demand for medication-related work. After nine months of implementation in general cardiology and heart failure clinical specialties, the nurses and providers were surveyed post-implementation.
Evaluation/outcome: Post-implementation of clinical pharmacists in the ambulatory care setting, the nurses stated that they had gained time in their day for other clinical work due to a decrease in medication insurance authorizations, a reduction in message basket volume, and an increase in pharmacist-assisted medication counseling. Additionally, the providers reported that medication adherence, affordability, and patient access to medications had greatly improved.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Janine Blezien, BSN, RN | Sarah Johnson, DNP, MSN, RN, CNL, Clinical Manager, Rush University Medical Center | Marlene Roman, BSN, RN | Sierra Weathers, MSN, RN, APRN
Updated: 03/22/23
Updated: 03/22/23
The creation of the ambulatory care management RN model seeks to establish, define, and distinguish the unique role the nurse plays in community care and population health which includes chronic disease management, transitional, and longitudinal care. As the value-based approach continues to impact how healthcare organizations deliver care, the demand for care management services has increased in the ambulatory care setting (Karam et al., 2021). Ambulatory care management registered nurses (ACMRN) play an integral role in providing safe and quality patient care which can lead to improved patient outcomes and satisfaction. In addition, the ACMRNs help reinforce the effective and efficient use of healthcare resources related to the complex care of patients in the community. According to the American Nurses Association (ANA) (n.d.), care coordination is emphasized as being a key tool in improving patient health and patient satisfaction while decreasing overall costs by hospitals, health systems, and payers.
In addition to having a practical use for the nursing model, nurses in an ambulatory care management setting at a large, academic medical center in the Midwest historically felt underutilized and experienced decreased engagement due to inconsistent nursing involvement and leadership. In an effort to establish the team as a professional specialty, a model of care was developed as the framework standardizing the ACMRN practice and making the work more meaningful. The intention with the creation of this model is to increase nursing engagement and retention while decreasing overlap amongst other disciplines within the healthcare setting.
The ambulatory care management RN model consists of five pillars describing how patients, families, invested partners, and the interdisciplinary team are engaged by the nurse care manager. Pillar 1 has a focus on population health using risk stratification tools while addressing social determinants of health and needs assessments. Pillar 2 and 3 focus on longitudinal care by having the tools to effectively differentiate episodic versus longitudinal needs. These pillars require a partnership with the patient, family, and ACMRN to develop and maintain goals through active participation, care plans, and interdisciplinary collaboration. Pillar 4 focuses on transitions of care, a time when patients can be vulnerable. This pillar bridges the gap from discharge to follow up appointment with a focus on symptom management, medication reconciliation, and education. The final pillar in the model highlights the important role the ACMRN plays in chronic disease management. Nurse care managers play a pivotal role in delivering an integrative, evidence-based approach to longitudinal care, patient education, and ongoing support. Tools utilized include risk stratification, assessments, and the development of an individualized care plan.
In addition to having a practical use for the nursing model, nurses in an ambulatory care management setting at a large, academic medical center in the Midwest historically felt underutilized and experienced decreased engagement due to inconsistent nursing involvement and leadership. In an effort to establish the team as a professional specialty, a model of care was developed as the framework standardizing the ACMRN practice and making the work more meaningful. The intention with the creation of this model is to increase nursing engagement and retention while decreasing overlap amongst other disciplines within the healthcare setting.
The ambulatory care management RN model consists of five pillars describing how patients, families, invested partners, and the interdisciplinary team are engaged by the nurse care manager. Pillar 1 has a focus on population health using risk stratification tools while addressing social determinants of health and needs assessments. Pillar 2 and 3 focus on longitudinal care by having the tools to effectively differentiate episodic versus longitudinal needs. These pillars require a partnership with the patient, family, and ACMRN to develop and maintain goals through active participation, care plans, and interdisciplinary collaboration. Pillar 4 focuses on transitions of care, a time when patients can be vulnerable. This pillar bridges the gap from discharge to follow up appointment with a focus on symptom management, medication reconciliation, and education. The final pillar in the model highlights the important role the ACMRN plays in chronic disease management. Nurse care managers play a pivotal role in delivering an integrative, evidence-based approach to longitudinal care, patient education, and ongoing support. Tools utilized include risk stratification, assessments, and the development of an individualized care plan.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/23
Updated: 03/22/23
Purpose: Gain insights into how mapping and advocating every new patient’s cancer journey led this nurse navigation department to rich outcomes for both patients and nurses. Nurse navigators at a cancer center recognized an opportunity to improve new patient services and increase nursing value for patients at the beginning of their cancer journey. Goals of this initiative were to promote health and wellness for patients and nurses’ satisfaction with their practice.
Description: Nurse navigators aim to provide patient-centric education, early diagnosis/treatment options, improved patient adherence and engagement, prevention of delays in treatments, and enhanced clinical outcomes. The nurse navigation department sought to improve their workflow and deliver top-of-license nursing practice. Within a cancer center-wide access redesign project, nurse navigators took the opportunity to take a critical look at their contributions to new patients. The team formed a small committee comprised of tenured nurses and nurses new to the department to assess nurse navigators’ standard workflows. First, the committee reviewed the center’s community needs assessment and the goals of Healthy People 2030. The cancer center’s community needs assessment revealed that 83% of area residents rated the overall health of the community as “fair” or “poor,” with additional barriers to care that include difficulty navigating the health care system, literacy, housing, safety, transportation, limited financial resources, language, and cultural barriers. With this information in mind, the committee implemented an education series targeted to the whole department. Education was provided during regular in-services and staff meetings. The education included information about internal and community-based supportive services. The navigation team learned how to use EMR functionality to independently refer patients to internal cancer center services. Subsequently, the team shared community resources and websites amongst the group and stored the information in a shared electronic folder. Speakers from community non-profits were invited to present at staff meetings. The team standardized the patient interview and EMR documentation. A survey was sent to the nurse navigators pre- and post-implementation looking for perceptions of top of license.
Evaluation/outcome: Prior to the implementation of navigator education of supportive resources and learning how to independently place EMR referrals, a baseline of 2% of patients were referred to supportive services. Standardized questions asked during the navigator-new patient interview helped identify barriers and prompted the navigator to refer patients to resources. A 250% increase over baseline (7%) was achieved. The top-of-license survey demonstrated improvement in nurse satisfaction in emotionally supporting and educating patients, incorporating patient data into the plan of care, evaluating the plan of care with patients, coordinating care with clinical team members, and working at top of license. This patient-centric initiative improved the new patient’s experience with nurse navigators and increased support to patients through referrals to needed services. Additionally, this project improved nursing satisfaction with several top of license activities.
Description: Nurse navigators aim to provide patient-centric education, early diagnosis/treatment options, improved patient adherence and engagement, prevention of delays in treatments, and enhanced clinical outcomes. The nurse navigation department sought to improve their workflow and deliver top-of-license nursing practice. Within a cancer center-wide access redesign project, nurse navigators took the opportunity to take a critical look at their contributions to new patients. The team formed a small committee comprised of tenured nurses and nurses new to the department to assess nurse navigators’ standard workflows. First, the committee reviewed the center’s community needs assessment and the goals of Healthy People 2030. The cancer center’s community needs assessment revealed that 83% of area residents rated the overall health of the community as “fair” or “poor,” with additional barriers to care that include difficulty navigating the health care system, literacy, housing, safety, transportation, limited financial resources, language, and cultural barriers. With this information in mind, the committee implemented an education series targeted to the whole department. Education was provided during regular in-services and staff meetings. The education included information about internal and community-based supportive services. The navigation team learned how to use EMR functionality to independently refer patients to internal cancer center services. Subsequently, the team shared community resources and websites amongst the group and stored the information in a shared electronic folder. Speakers from community non-profits were invited to present at staff meetings. The team standardized the patient interview and EMR documentation. A survey was sent to the nurse navigators pre- and post-implementation looking for perceptions of top of license.
Evaluation/outcome: Prior to the implementation of navigator education of supportive resources and learning how to independently place EMR referrals, a baseline of 2% of patients were referred to supportive services. Standardized questions asked during the navigator-new patient interview helped identify barriers and prompted the navigator to refer patients to resources. A 250% increase over baseline (7%) was achieved. The top-of-license survey demonstrated improvement in nurse satisfaction in emotionally supporting and educating patients, incorporating patient data into the plan of care, evaluating the plan of care with patients, coordinating care with clinical team members, and working at top of license. This patient-centric initiative improved the new patient’s experience with nurse navigators and increased support to patients through referrals to needed services. Additionally, this project improved nursing satisfaction with several top of license activities.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Faith Jones, MSN, RN, NEA-BC, Care Coordination and Lean Consultant, HealthTech
Updated: 03/22/23
Updated: 03/22/23
Transitional care management (TCM) is a primary care service, and the payment model agrees. The inpatient setting is penalized for readmission, whereas the primary care setting is rewarded. This poster will shine a spotlight on why and how ambulatory care nurses must lead the TCM process. The poster will discuss building expectations and relationships with inpatient case management colleagues to ensure that an effective handoff is completed to prevent care gaps during one of the most vulnerable times for patients – transitions of care. The poster will also address how the TCM requirements for payment are aligned with the care models that highlight team-based care and having the ambulatory care nurse work to the highest level of education and training.
TCM has been a reimbursable care coordination model since 2013, yet 10 years later, many primary care practices have not embraced this service. Our Medicare beneficiaries still have an almost 20% readmission rate. The time is now for ambulatory care nurses to lead this process to improve patient outcomes and improve their quality of life.
TCM has been a reimbursable care coordination model since 2013, yet 10 years later, many primary care practices have not embraced this service. Our Medicare beneficiaries still have an almost 20% readmission rate. The time is now for ambulatory care nurses to lead this process to improve patient outcomes and improve their quality of life.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/23
Updated: 03/22/23
Background and significance: Sepsis is the body’s overwhelming, life-threatening response to infection, this can lead to organ failure and death. 60% of hospital readmissions occur within thirteen days of discharge. In CY2019, Michigan Medicine’s sepsis population had a 30-day all-cause readmission rate of 22%. In 2020, the Michigan Medicine clinical design and innovation (CDI) team with nurse care navigators (CNs) and TOC pharmacists, partnered to review data surrounding sepsis patients and hospital readmission to create a sepsis TOC model. The sepsis TOC model utilizes embedded nurse CNs to provide additional TOC calls specific to patients discharged following a sepsis diagnosis. Transition of care (TOC) is defined by any movement of a patient from one setting of care to another.
Goals: The goal of this project was to decrease the all-cause readmission rate from 22% to 21% by enhancing the existing TOC service.
Methods and evaluation: The sepsis TOC team assembled in September 2020. Sepsis (post-sepsis syndrome) M-learning was amended to serve outpatient clinical staff.
On 6/16/2021, the sepsis TOC bundle went live for discharged patients with a MM PCP. Patients were contacted within 2 business days, then referred to embedded CN for additional follow-up, with weekly contact for 4 weeks and assessment for longitudinal support. They were contacted by a PharmD within 3-5 business days and given a 5-question survey. On 10/5/21, the process for discharged patients with an external PCP went live. These patients were referred to the patient monitoring at-home program.
Result: Data collected from 1/1/2021 to 12/12/2021 revealed pre-pilot readmission rate of 22.09%, whereas pilot readmission rate of 19.86%. Data collected from 6/16/2021 to 12/12/2021 revealed not-in-pilot readmission rate of 21.03% whereas in-pilot readmission rate was 19.86%.
Significance/conclusion: This new process did not impact the workload of the CNs. The impact this new process has on reducing hospital re-admissions was extremely successful.
Summary: The sepsis TOC bundle pilot was successful at decreasing readmission rates of sepsis patients by providing enhanced follow-up with TOC pharmacist and embedded nurse CNs.
Goals: The goal of this project was to decrease the all-cause readmission rate from 22% to 21% by enhancing the existing TOC service.
Methods and evaluation: The sepsis TOC team assembled in September 2020. Sepsis (post-sepsis syndrome) M-learning was amended to serve outpatient clinical staff.
On 6/16/2021, the sepsis TOC bundle went live for discharged patients with a MM PCP. Patients were contacted within 2 business days, then referred to embedded CN for additional follow-up, with weekly contact for 4 weeks and assessment for longitudinal support. They were contacted by a PharmD within 3-5 business days and given a 5-question survey. On 10/5/21, the process for discharged patients with an external PCP went live. These patients were referred to the patient monitoring at-home program.
Result: Data collected from 1/1/2021 to 12/12/2021 revealed pre-pilot readmission rate of 22.09%, whereas pilot readmission rate of 19.86%. Data collected from 6/16/2021 to 12/12/2021 revealed not-in-pilot readmission rate of 21.03% whereas in-pilot readmission rate was 19.86%.
Significance/conclusion: This new process did not impact the workload of the CNs. The impact this new process has on reducing hospital re-admissions was extremely successful.
Summary: The sepsis TOC bundle pilot was successful at decreasing readmission rates of sepsis patients by providing enhanced follow-up with TOC pharmacist and embedded nurse CNs.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
