Purpose: Hypertension (HTN) has been identified as the most common medical diagnosis in the US and individuals with social, economic, and cultural factors have higher prevalence and poor control of their ability to self-manage the disease. HTN has also been associated with the highest risk for mortality related to cardiovascular disease. Care coordination and the use of community health workers to provide resources, especially those related to social determinants of health (SDOH), can improve patient engagement, support improved quality of care, and can potentially cascade into improved health and well-being outcomes.
Methodology: Using the PDSA methodology, the following EBP research project was implemented: 1) Two chronic disease nurses filtered a facility-specific chronic disease dashboard to identify patients ages 40-75 with a clinical diagnosis of HTN and uncontrolled B/P ≥140/90 after two PCP visits.
2. Motivational interviewing was used to identify patients who did not express or exhibit readiness for self-care management, which was used as exclusion criteria.
3. For the patients who met the inclusion criteria (n=51), the nurses implemented targeted nursing interventions over a 3-month period (April 2023 to June 2023) which included: a) comprehensive patient education tailored to the individual patient’s needs, b) home B/P monitoring with log book, c) collaborative care planning, d) monthly outreach via telehealth check-in and in-person nurse visits, and e) SDOH screening and referrals to CHWs for internal/external resources as indicated.
Analysis: Within a 3-month period, 76% of patients with uncontrolled HTN reduced their clinic B/P from ≥140/90 to ≤130/80 (n=34). Monthly telehealth outreach/education and SDOH screening were completed in 100% of the patients (n=51). SDOH were addressed using grant-funded home B/P devices for patients with financial needs (n=12; 24%) and CHW referrals for housing, food, transportation, smartphone access, educational, employment, and legal assistance resources (n=7; 14%).
Results: This quality improvement project showed that 76% of patients with clinic B/P ≥140/90 improved their clinic B/P to ≤130/80 over a 3-month period. Using telehealth outreach services and addressing SDOH can support engagement and quality patient outcomes.
Learning outcomes: 1) Discuss the relationship between social determinants of health and hypertension. 2) Describe the targeted nursing interventions used in hypertension management. 3) Identify multiple modes used to address the social determinants of health.

Background: Access in health care has been an identified topic of interest to companies, as well as patients. A person’s ability to access health care has a direct effect on their health and well-being. Access to health care can include available services, timeliness of services, and availability of qualified providers. In a surgical oncology clinic, Press-Ganey scores have been below targeted level of achievement in the category of access to care. Items affecting this score include their ability to access their nurses and/or provider team for problems and questions. Survey items, such as ease of getting clinic on phone, the clinic’s promptness in returning phone calls, and phone calls answered during same day have all been consistently needed improvement over the past year in a surgical oncology clinic.

Aim: The aim of this project was to implement a nurse triage role to increase the patient satisfaction mean scores by 10% in the Press-Ganey domain of access to care 3 months, specifically for the access to staff by telephone during and after-clinic hours, for surgical oncology patients in the League City Houston Area Location (HAL) within 9 months of implementation.

Process of implementation: The intervention consisted of developing and implementing a triage nurse role for the clinic setting at the League City HAL. This triage nurse’s role was to answer telephone calls during clinic hours and to follow up with telephone messages during the same day. Collaboration with providers was necessary to develop processes for issues that warranted inquiry beyond the clinical nurse. Additionally, the triage nurse provided follow-up phone calls to all new patients, procedures, and consults to address any needs. The number of phone calls received, number of phone calls made, and patient reasons for concerns were all tracked by the triage nurse. These results were reviewed monthly to identify any trends in care and use of the triage nurse line.

Results: Data were analyzed by comparing the Press-Ganey pre- and post-implementation mean scores in the domain: access to care 3 months. Results reflected a 5% increase in scores for the question “clinic’s promptness in returning calls,” comparing the 9 months pre- and post-implementation. Results also reflected a 28% increase in scores for the question “phone during office hours answered same day,” comparing the 9 months pre and post implementation.

Relevance in clinical practice: The implementation of a nurse triage role in a surgical oncology clinic facilitated patient communication and improved patient access to health care. While there was a slight increase in scores for returning telephone calls, the dedicated triage role significantly improved same day answering of the telephone calls, thus mitigating risks post-surgery by addressing any issues real time with the patients before they become more severe.

Purpose: Ambulatory care nursing models can vary by location, specialty, or nursing role. This variation was true for primary and specialty clinics across a large academic health system. Ambulatory care workflows lacked clarity for nursing roles within the interprofessional care team model. This variability contributed to confusion among patients and unclear expectations for care teams. Standards of care can facilitate efficient management of evolving ambulatory care nursing responsibilities (American Academy of Ambulatory Care Nursing, 2023). The purpose of this presentation is to examine a new standardized clinical care team matrix adopted by the organization to enhance ambulatory care delivery models while prioritizing top-of-licensure practice for nurses and interprofessional team members.

Description: The ambulatory care team improvement and optimization (ACTION) program began as a pilot by the ambulatory care nursing department in Fall 2021. Methods included using focus groups and a design team including leaders, front-line nursing, and clinic staff to assess current ambulatory care practice and develop a standardized care team matrix. The matrix clearly defined the tasks and actions of various nursing roles and interprofessional team members, including clinical nurses and nurse coordinators, medical assistants, advanced practice providers, medical scribes, and schedulers. The matrix outlined each team member’s standard work in accordance with their role’s top-of-licensure scope of practice. During the five-month program, groups met monthly with nursing leaders to monitor alignment with the team matrix and metrics in patient-reported satisfaction (nursing communication and staff working well together) and employee-reported engagement (feeling productive and engaged). Due to the pilot’s success, the program expanded to a second cohort from September 2022 to February 2023, with implications to build a sustainable clinical model that continuously optimizes ambulatory care professional practice.

Evaluation/outcome: Our healthcare system has had two ACTION cohorts. Cohort 1 had a total of 42 team members across 7 primary and specialty care clinics and cohort 2 had a total of 67 team members across 8 specialty clinics.

Teams focused on various aspects of optimization, including interprofessional care team role alignment and optimization, utilization of nurse-led visits, electronic health record (EHR) message management, and prior authorization streamlining.

ACTION program results included the creation of a standard workflow for medical assistants to schedule peer-to-peer reviews for prior authorizations, enhanced EHR subject messaging to allow appropriate message triage and review, and implementation of 517 nurse-led visits to increase patient access. Patient-reported scores on staff working well together increased from 82.4% to 87.9%, with nurse communication scores increasing from 86.5% to 87.4%. Staff-reported feelings of engagement increased from 86% to 92%.

Given the program’s success, the next ACTION cohort expanded to 38 additional clinics across the organization.

The ACTION program demonstrates ambulatory care optimization strategies leading to increased staff and patient satisfaction and care quality. The standardization initiatives of the program have positively impacted ambulatory care in primary and specialty care clinics and have implications that can be sustainably scaled across academic health systems.

Chrystal Lewis discloses that she serves as a presenter for Practicing Clinicians Exchange.

Purpose: The purpose of this presentation is to discuss the implementation and impact of nurse-led visits in ambulatory specialty care settings at an academic medical center.

Description: Access to health care in the ambulatory care setting can be challenging. Nationally, there is an average 20.6-day wait for an initial appointment with a primary care provider. This wait can be even longer for specialty care providers with a national average appointment wait time of 26 days. Nurse-led visits have gained momentum as a method of optimizing healthcare delivery, improving access to care, and enhancing patient outcomes.

Nurse-led visits, referring to the utilization of current procedural terminology (CPT) code 99211, are a promising approach to enhance patient care in specialty areas within academic medical centers. These visits involve registered nurses (RNs), including clinical nurses and registered nurse coordinators, who possess specialized training and expertise to provide comprehensive care within their specific specialty. Nurse-led visits encompass a wide range of services, including disease management, treatment follow-up, patient education, and coordination of care. Goodman et al. (2021) introduced nurse-led patient education visits in which the nurse would spend an extra 20-40 minutes with the patients to conduct additional patient education. Nordlund et al. (2022) found that registered nurse-led consultations were an effective strategy to meet demand in Swedish pediatric emergency departments.

Evaluation/outcome: In the six-month period of December 2022 through May 2023, 30 clinics participated in nurse-led visits and 125 nurses conducted these visits, with a total of 2,509 nurse-led visits completed during this period. However, when we attempted to do analysis of outcomes, we found a wide variation in charting practices, scheduling of nurse-led visits, and subsequently successful billing for nurse-led visits, making it near impossible to maintain clean data collection or analysis. Anecdotally, our nurses report using nurse-led visits as an effective strategy to improve care delivery. Implications for future practice are to build explicit and consistent charting templates, scheduling workflows, and billing coding. Future research implications include investigating the impact nurse-led visits have from the patient and caregiver, nurse, and provider perspectives. Additional future research is needed to systematically investigate the anecdotal perceptions as well as the operational utility of nurse-led visits.

Chrystal Lewis discloses that she serves as a presenter for Practicing Clinicians Exchange.

Purpose: The purpose of this presentation is to share an ambulatory care shared governance task force’s journey from its original purpose of reducing patient falls in ambulatory care areas in a large, multi-site ambulatory care system to educating staff about and promoting the use of the organization’s incident reporting system.

Description: Falls are identified as a nursing-sensitive indicator and safety event for the ambulatory care setting. Three service line-specific shared governance councils identified a need to systematically address patient falls in ambulatory care. The shared governance council created a patient falls-specific task force (n= 13 members) with representation from 4 clinics. Staff roles included unlicensed assistive personnel, registered nurses, quality, informatics, nursing director, and patient safety. Members noted that recall of patient falls and near misses within the past 6 months (n=7) did not match the number of falls recorded through the organization's safety incident reporting system (n=5). The falls reported did not match the patient identifiers for those recalled. The task force began a QI project using the PDSA cycle framework to address the incongruence between recalled falls and reported falls. The task force conducted an informal voluntary survey of front-line staff (n=71) regarding reporting system utilization. Survey responses noted 49% (n=35) of staff had never submitted an incident report. Several barriers to usage of the reporting system were cited, with not receiving information on incident reports occurring in the department (n=38; 54%), time to complete (n=29; 40.8%), and lack of knowledge of how to complete (n=25; 35%) as the top three barriers.

These findings represented a need to pivot the initiative to improving the collection and sharing of data on safety incidents to focus on a culture of safety that could drive future quality improvement work. The task force met with stakeholders from quality and department/nursing leadership to provide visibility to safety reporting numbers via dashboard reporting and engage them as key stakeholders in improved incident reporting.

Evaluation/outcome: The task force identified staff education initiative as a key intervention to improve knowledge and use of the incident reporting system among all ambulatory care clinic team members, which was like what Hamed and Konstantinidis (2022) found. The task force utilized quality and ambulatory care leadership partners to develop one-page educational guides on incident reporting for easy sharing via email and posted on visibility walls. Falls task force members also partnered with department leaders to regularly share data with front-line staff on submitted incident reports, including patient falls, and discuss and celebrate reported patient outcomes with the goal of enculturating incident reporting in the ambulatory care setting. Integration of the incident reporting system into the electronic health record also improved ease of use for staff. The implementation of the incident reporting training is currently in progress. Future goals for the task force include a 6-month re-survey of staff and review of incident reports to determine if the implementation improved reporting system utilization and if accurate reporting of patient falls warrants further quality improvement work.

Chrystal Lewis discloses that she serves as a presenter for Practicing Clinicians Exchange.

Purpose: The National Academy of Medicine has recognized a shift to ambulatory care nursing over the next 10 years, triggering an up rise of nursing students entering this setting. With this new shift and the minimal exposure nursing students receive in school, a knowledge deficit has been identified related to the role of nursing in this care setting. Through a partnership with nursing scholars and a culmination of follow up dialogue with students and preceptors, a need to bridge the gap between nursing school curriculum and the role of the nursing students in clinical rotations in the ambulatory care setting was identified.

Learning outcome: Identify strategies and tools to support orienting nursing students to the ambulatory care environment.

Description: Nursing students lack familiarity on the nurse role in the ambulatory care setting and how skills performed translate to the traditional inpatient nurse role. Along with the varied level of education around ambulatory care in nursing schools, the perception of care portrays minimal hands-on skill. Providing a structured orientation, case studies, and focused plans of care, the importance of how nurses deliver high-quality care in a non-traditional care setting will help to align the focus of their clinical rotation. The program was originally established through collaboration with nursing scholars, professional development, and clinical leaders to support immersion (capstone/practicum,180 hours) rotations and has been expanded to include community health (64 hours) rotations.

Evaluation/outcome: The rollout of this orientation program started in a phased approach, targeting pilot areas with experience in hosting nursing students. The second phase included program changes, pre-rotation survey completed by the nursing student, and a post-rotation survey completed by the nursing student and preceptor. Successful outcomes are identified through formative and summative evaluations and a completed orientation plan that include action items, case studies, and plans of care.

From February to May 2023, ambulatory care departments hosted 16 nursing students. A pre-rotation survey specifically for the students was added in June to establish their baseline understanding of ambulatory care nursing. The data from this survey guided formative check-ins with the preceptor throughout the rotation. A post-rotation survey assessed the program’s value, identified gaps, and provided recommendations to further expand the program. Overall feedback from nursing students and preceptors who have used this orientation program has been positive, informative, and constructive.

Purpose: Our large academic medical center is an enterprise covering both community outpatient practices and hospital-based outpatient departments (HOPD). Although we share regulations with Centers for Medicare and Medicaid Services (CMS), HOPD’s are driven by the Joint Commission (JC) Standards. With the understanding of both CMS and JC standards along with hospital policy and community standards, a council comprised of clinical educators and ambulatory care clinical program coordinators was to developed to review activities, interventions, and roles for nurses and other clinical staff to ensure they can safely perform under their specific scope of practice.

Learning outcome: Identify strategies and tools to support delineation of scope of practice for outpatient departments.

Description: The scope of practice (SOP) council is a collaborative decision-making group developed to provide clarity and evidence-based recommendations for tasks constituting the practice of medicine, independent professional judgement, or the making of clinical assessment centered on community and regulatory standards not outlined in organizational policies. The SOP council developed education providing guidance and detailed requirements for SOP request submissions.

Evaluation/outcome: Any clinical role, including staff and/or leaders, are able to submit a request. A new request should be considered if there is a question regarding a new clinical skill, process, procedure, or equipment or there is a skill already listed on the SOP index and a new department would like to be added. Each submission requires evidence or research supporting the request. When a request is submitted, council members are notified and perform a separate search using Vizient, AAACN, ANA, professional organizations, and hospital policy. The request is discussed and is either approved, denied, or pended for additional details. Once a recommendation is made, the decision is presented to the director of ambulatory care clinical programs and the ambulatory chief nursing officer (ACNO) for review and approval. The submitter, along with the clinical educator for the department, are then notified to ensure competency training is validated, if necessary. The approved request is added to the SOP index. Since the inception of the SOP council in 2021, there has been an overall increase in the queries related to scope of practice, with 28 official requests. Of those requests, there were fifteen approvals, four denials, and nine requests that were escalated to operational leadership for further review.

Controlling high blood pressure (BP) is important due to its impact on cardiovascular and renal health. A joint policy statement from the American Heart Association and American Medical Association established self-measured BP as a cost-effective way to manage hypertension (HTN). The literature states self-measured BP can diagnose white coat HTN, reflect a response to antihypertensive therapy, and potentially improve patient adherence to therapy. A large percentage of patients self-monitor, but barriers exist to the use of patient’s readings in the healthcare setting including lack of institutional infrastructure, providers fearing increased electronic or phone communications if home BP measurements are encouraged, and patients thinking their provider doesn't care about their self-measured results.

This project successfully developed a standardized approach to incorporate self-measured BP readings into the medical record, which yielded usable data for patient care and quality metrics. The preferred workflow utilized a patient-entered flowsheet (PEF) where patients electronically entered their self-measured BP readings. Nurses and providers collaborated to provide feedback on this tool and identified improvements needed to meet the clinic’s needs.

Evaluation of the PEF project yielded positive results and highlighted its potential to capture home BP readings, improve blood pressure management, and enhance patient involvement in health care. Utilization of home BP readings is not a new practice, but the PEF standardized the documentation and utilization of them.

Overall, 51% of patients who agreed to use the PEF, entered their data. This is comparable to the 52% of patients who follow through with a future nurse visit for BP recheck when ordered. Of those that entered data, 51% of those patients had a BP that was in range by the end of the 2-month pilot period, which contributed to a commendable average increase of 3.67% in the controlling high BP metric for the team. Utilization of the PEF led to a 24% reduction in nurse visits for BP rechecks, which opened access to other types of nurse visits and emphasized the PEF’s effectiveness in providing patients with a more convenient way to manage their health.

The project highlighted that patients were more likely to engage in the PEF when it was discussed during a provider visit, compared to receiving only a portal message, and emphasized the importance of provider-patient communication in promoting engagement. To address initial patient engagement challenges, the development and introduction of patient education materials, delivered electronically or in-person, played a pivotal role in increasing patient understanding and participation. Outcomes demonstrated the success of the PEF in promoting patient engagement, improving BP control, and streamlining healthcare processes. The positive results from this pilot supported the broader implementation of PEF for home BP readings throughout our clinics and paved the way for enhanced patient-centered care.

Purpose: Enrollment into the anticoagulation program is a complex transition of care. Nurses work as vigilant guardians managing warfarin dosing and teachers assuring patients have the knowledge to reach and safely maintain therapeutic range. Recognizing the importance of resource stewardship, RNs sought to utilize the skills and abilities of desk operation staff (DOS) colleagues in the enrollment process while not compromising the RN role of guardians and teachers. The aims were 1) decrease steps of the new patient enrollment process completed by RNs but not needing RN licensure by 90% without adversely impacting patient safely and 2) increase the number of patients taking the warfarin education class by 25%.

Description: An RN team worked to standardize processes and define gaps for completing enrollments. CNS and RNs collaborated to transition experienced nurse's knowledge into a workflow allowing non-licensed staff and RNs to partner with onboarding new patients. DOS use a comprehensive resource to complete a chart review. RNs use information to determine eligibility for program and plan of care. DOS welcomes patient, reviews program information, sends educational materials, assures HIPPA documentation is completed, and schedules educational class and first RN visit. The RN focuses on chronic care management (CCM) processes allowing for billing, patient specific education, and warfarin management.

Evaluation/outcome: 26 of 28 tasks not needing RN licensure were transitioned to DOS accomplishing the aim. Three potential privacy concerns were eliminated. Patient education class numbers nearly doubled. RN FTE decreased from 2.0 to 1.3 FTE per day. The number of patients enrolled in CCM significantly increased. Feedback from RNs revealed patients are better prepared to receive patient education with scheduled appointments. The warfarin class prepared patients to engage with RNs about lifestyle modifications that directly affect their TTR. Despite initial concerns, partnering with DOS to complete enrollments has proven beneficial to the practice and the patients.

Purpose: The purpose of this project was to improve staff comfortability in addressing patients with behavioral health challenges.

Description: Behavioral health crises occur in the outpatient setting, but staff do not experience the same support or processes as inpatient services. A generalized literature review revealed minimal results regarding staff education in behavioral health topics and safety workflow for patients with suicidal ideation (SI) within ambulatory care.

In December 2022, a survey assessing baseline comfort and evaluation of current behavioral health practices was distributed to staff at a primary and seniors care clinic. Results indicated education was needed related to patient suicidal ideation and the associated communication and management techniques. Stakeholders provided feedback during the creation of the background education, communication techniques (including a dot phrase for nursing), and safety workflow (delineates roles for each staff member) for patients with suicidal ideation. In April 2023, education was presented, and the initial survey was repeated to reassess comfortability with SI management. In June 2023, a mock behavioral health emergency was conducted, and staff completed the survey again to evaluate overall retention of education and comfortability levels.

Evaluation/outcome: After the education was completed, two post-surveys were completed to assess sustainability of the education and SI management process in April and June. Using a five-point Likert scale ranging from very uncomfortable to very comfortable, the results demonstrated a decrease in staff feeling uncomfortable or very uncomfortable while managing SI. Staff had an improvement in comfortability as shown by a decrease in the number of staff responding as “somewhat uncomfortable” or “very uncomfortable.” In December, using a five-point Likert scale “How comfortable are you asking or talking to patients about mental health concerns?” survey revealed that 5 of 34 (5/34) respondents were either “somewhat uncomfortable” or “very uncomfortable.” In April 2023, 1/29 indicated they were either “somewhat uncomfortable” or “very uncomfortable.” In June 2023, 2/30 indicated they were either “somewhat uncomfortable” or “very uncomfortable.” The “n” number varied due to availability of staff. Results indicated an increase in staff comfortability in addressing patients with behavioral health challenges. Education combined with creation of a dot phrase and safety workflow provides resources for staff to maintain comfortability and ensure patient safety. Next steps include sharing education and workflow with other ambulatory care clinics. Limitations included required continuity of survey.