Purpose: To create an enhanced primary care nurse role, practicing at the full scope of license in community-based primary care, resulting in sustainable solutions to address the primary care nursing workforce shortage in Indiana, enhance the health and well- being of our patients, address social determinant factors, and recruit and train nursing students in community-based primary care.

Background/significance: Currently, there is no defined role for an enhanced primary care RN. According to the Indiana Data Report 2015, only 8.9% of all RN’s (n=6,009) who completed their survey work in an ambulatory care setting (Vaughn et al, 2015). By creating this enhanced role, population health, social determinants of health, chronic disease management, care coordination, transitional care management, mental health, and pain management can be addressed to increase quality care and prevent hospital admissions.

Methods: In addition to creating a new top of license role for the registered nurse, a primary care curriculum for pre-licensure baccalaureate nursing students and post-licensure RN-BSN students was created. The current state of curricula does not involve education in primary care nursing. In partnership with The University of Indianapolis School of Nursing (UIndy), a primary care overview course, and subsequent primary care nursing classes were developed and are currently being implemented with 19 credit hours and 150 clinical hours, resulting in the first minor in primary care nursing in the country. With these implementations, a pipeline was created for entry into primary care which will increase patient access to primary care services and improve population health outcomes. To successfully train students to be effective primary care nurses, an ambulatory care preceptor training course was initiated.

Result: Nine students were enrolled in the first primary care overview course at UIndy. Three enhanced RNs in seven clinical sites were secured in clinical rotations, and seven preceptors were trained. Standardized instruments are being utilized to measure student perceptions of their curriculum and preceptors, preceptor perceptions of their training, and patient perception of their care rendered in the primary care sites. These tools include The Self-Efficacy and Performance in Self-Management Support tool (SEPSS-36, Duprez et al, 2016), Nursing Preceptors’ Attitudes and Perceptions Questionnaire (Kalischuk et al, 2013), The Preceptor’s Perception of Benefits Rewards Scale (PPBR) (Dibert, 1993), and The Clinical Learning Environment, Supervision and Nurse Teacher Scale (CLES+T) (Saarikoski et al, 2008). Data is currently being evaluated to identify trends in patient perception and team cohesiveness via standardized survey instruments.
Conclusions: An enhanced RN role in primary care nursing is necessary to improve access to health care, yet it is not implemented in primary care settings, where nurses are typically used in triage roles. The challenge remains that while this is needed in practice, it has not been a part of curricula in nursing. A minor in primary care nursing in an undergraduate nursing program, along with an enhanced RN role in six practice settings were developed to revolutionize the role of primary care nursing, create a pipeline for new nursing graduates to enter primary care nursing, and improve patient outcomes.

Purpose: To describe the development and implementation of Rush Health’s care management (CM) program for primary care patients and the efficacy of strategic value-based care initiatives as it pertains to addressing patient chronicity and utilization trends.

Description: The whispered concept of value-based care began circulating throughout the healthcare industry roughly ten years ago and over time has grown louder into a large roar, impacting how healthcare organizations are rewarded for performance. The shift from fee-for-service to fee-for-value broke tradition and thus mobilized healthcare leaders to think of innovative strategies to ensure better results as it relates to quality, cost, and outcome measures. One approach proven effective in addressing the triple aim and improving the health of populations is the implementation of care management (CM) programs in primary care settings (Agency for Healthcare Research and Quality, 2015).

Rush Health, an affiliate of Rush University System for Health, thrives on innovation and proactively took on the challenge of embracing value-based care. In 2016, Rush Health, a clinically integrated network of physicians and hospitals, began overseeing several value-based care payer contracts where CM services are a requirement for reimbursement. In less than two years, Rush Health developed a CM program utilizing evidence-based research to effectively address primary care patients’ needs; teams of nurses, social workers, and other allied health professionals focus their activities on care transitions, disease management, abhorrent utilization, and care gap closure.
During the development of the CM program, emphasis was placed on incorporating both qualitative and quantitative resources to ensure proper identification of high-cost patients. The inclusion of holistic and patient-centered approaches to health was also of importance as this yielded comparison to other best practice models (Healthcare Transformation Task Force, 2018). Evidence-based health assessments were developed internally along with real-time discharge notifications and a comprehensive report that combines multiple patient data points and assigns “red flags” as risk indicators for care managers. The program also piloted an emergency department (ED) alternative mailing project to help redirect patients at risk for abhorrent utilization to urgent care.

With the help of actionable data, CM teams conduct patient outreach, complete assessments, follow up after discharges, and create care plans to proactively identify and address barriers to care. Today, the number of payer contracts has grown to account for over 100,000 patient lives, and the CM program has since been adopted by all Rush Health network members.

Evaluation/outcome: Due to the structure of Rush Health’s CM program, several payer contracts saw shared savings including a 17.5% per member per month savings ($757,750 annualized savings) for the management of a diabetic population in 2018. Regarding the targeted ED mailing pilot, there was a 1.6% decrease in ED visits during the three-month pilot compared to the control group who did not receive the mailing. In conclusion, there were documented cost savings and effective population health management since the inception of Rush Health’s CM program, indicating that the program’s design is directionally effective. Rush Health continues to optimize and monitor the program’s efficacy for future expansion.

According to Laviszzo-Maourey (2013), readmissions cost an estimated $26B annually with cardiovascular surgery (CV) readmissions averaging $13,500 (Shah et al., 2019). Preventing one readmission can have a profound impact. Team communication typically occurs in the acute phase, leaving post-acute providers to rely on ER visits and readmissions to manage patient needs.

Ineffective communication contributes to 30-day readmissions (Edelman, 2016). Ambiguous discharge orders, conflicting instructions, and lack of knowledge are areas of concern. The use of video call technology improves communication and possibly eliminates an ER visit that could lead to a readmission. Telehealth fosters a relationship among providers and improves patient satisfaction.

We identified 2 high-volume rehabilitation centers receiving CV surgery patients in 2018 (56%) and 2019 (37%). A guideline for communication was developed for the CV clinic and rehab center. Standardized questions were used. A video monitor and IPAD were installed at both sites. The CV nurse navigator used a report of the previous day’s discharges to coordinate a time for the video call. All calls were initiated within 24-48 hours of transition. This video call conversation included the patient, rehab RN, and CV nurse navigator. Discussions included any patient concerns and process issues with the transition of care. All calls were documented in the EMR and stored in a secure access database.

A total of 144 patients were discharged to the designated rehabs between August 2018 and September 2019. The historical group (n=77) received standard care which involved the CV nurse navigator to rehab RN telephone call using standardized questions. The intervention group (n=67) used video calls to enhance communication between RNs and included the CV patient. Calls for both groups occurred within 48 hours of discharge using standardized questions. Demographics were compared and found to be similar for both groups. The control group had a readmission rate of 23% (n=18) compared to 8.9% (n=6) in the intervention group. Identified clinical issues and patient concerns were addressed and resolved in the moment. Readmission reduction from rehab was achieved when standardized care included video calls. By improving transition communication, video calls increased the comfort level of rehab RNs caring for high-risk CV patients.

Although there was a challenge in coordinating the calls, it was not insurmountable. The time and cost of setting up video calls between the rehabilitation facility and the CV surgery clinic decreased our readmission rate and enhanced our relationship with our community partners, and patients expressed gratitude in the continuity of care.

References
1. Edelman, T. (2016). Reducing hospital readmissions by addressing the causes. Center for Medicare Advocacy. Retrieved from https://www.medicareadvocacy.org/reducing-hospital-readmissions-by-addressing-the-causes/
2. Lavizzo-Maourey, R. (2013, March 14). The Human Face of Hospital Readmissions. [Blog post]. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20130314.029239/full/
3. Shah, R., Zhang, O., Chatterjee, S., Cheema, F., Loor, G., Lemaire, S., …Ghanta, R. (2019). Incidence, cost, and risk factors for readmission after coronary artery bypass grafting. Journal of the Society of Thoracic Surgeons and the Southern Thoracic Surgical Association, 107(6), 1782-1789. doi: https://doi.org/10.1016/j.athoracsur.2018.10.077

Background/purpose: Patients with sleep apnea are often prescribed positive airway pressure (PAP) treatment. Some patients have difficulty consistently using a PAP machine due to problems such as air leak, mask discomfort, and dry mouth. Sleep medicine is growing rapidly, and the role of the ambulatory care registered nurse (RN) in the care of this population is evolving.

The purpose of this project is to evaluate the satisfaction and efficacy of a PAP troubleshooting clinic lead by a RN and a respiratory technician (RT). This clinic seeks to improve PAP compliance, increase PAP tolerability, increase PAP treatment efficacy, and assist sleep medicine physicians and advanced practice providers (APP) in the delivery of high-quality, efficient care of the sleep apnea patient.

Method/approach: The PAP troubleshooting clinic consists of a RN and RT with specialized knowledge about sleep apnea and PAP treatment. During a 30- or 60-minute clinic visit, these providers review the patient’s experience with PAP, assess mask fit, review PAP data and PAP settings, and recommend treatment adjustments for the primary sleep clinic provider’s consideration. Outcomes assessment includes satisfaction (a telephone survey one week after the visit) and efficacy (30-day data on overall use, mask leak, and days with ≥ 4 hours of use downloaded from PAP machines). To evaluate outcomes, patients receive a telephone call one week after the visit to assess ongoing success or failure post-visit. We estimated efficiency by calculating time of visits that would have otherwise required physician or APP.

Results: To date, 58 patients have received care in the clinic, and 56 (96.5%) patients reported they were satisfied/highly satisfied with the PAP troubleshooting clinic. From the sample, 43 (74.1%) patients were compliant with mask use over 30 days. 24 (55.81%) showed a greater than 10% reduction in mask leak after intervention. Ten patients (23.3%) achieved an improvement with a 10% increase in number of days with > than 4 hours of PAP use. Current patients continue to be monitored by the team and the clinic sees and monitors new patients. An estimated 55 hours of clinic time were reallocated from physicians and advanced practitioners to the RN and RT.

Discussion: Both patients and sleep clinic providers are very satisfied with the PAP troubleshooting clinic. Patients are referred to this clinic because they have significant issues with PAP usage and are at high risk of discontinuing use. Patients find the clinic helpful and encouraging, while sleep medicine physicians and APPs appreciate the assistance in helping patients succeed with PAP, especially during the 30-day time period where PAP compliance receives scrutiny from clinics and payers. A PAP troubleshooting clinic with a specialty-trained RN and RT is an effective way to improve patient PAP use, mask leak, prolonged use, and patient satisfaction. Importantly, this new clinical model offers a valuable alternative to provide patients with the appropriate level of care.

Westwood Treatment is a 39-chair infusion department that specializes in bio, chemo, and immunotherapies for patients of the University of Kansas Cancer Center. Increasing patient demand and complexity, as well as limitations on resources, has driven cancer center leadership to look at opportunities to better manage the needs of our customers and discern how to better accommodate the growing volume.

Using an optimized scheduling templates which ensured the appropriate number of patient starts, at any given time of day, with both maximum resource utilization and patient acuity dispersion. These optimized templates had to be built into the Cadence scheduling module of the EMR. Template ownership was assigned to the treatment nursing and clinical staff (rather than scheduling staff) who oversaw both the original build and continued maintenance.

Building those templates in EMR required novel utilization of the Cadence module, which was a significant departure from prior infusion scheduling practices. Rather than having 39 separate infusion chair resources assigned to the department, instead, a single department-wide resource was created which would represent all 39 chairs. Combinations of slot openings, appointment blocks, and visit type restrictions were then employed to guarantee the appropriate number of patient starts in accordance with the optimized templates. Schedulers required thorough re-education, training, and at-elbow support to become comfortable navigating the new look and feel of infusion scheduling.
A nursing allocation tool was developed within the predictive scheduling application. This tool provided for the automatic assignment of patients to nurses based upon certain safety constraints (including patient acuity as well as limitations on number of first treatment patients, the overall number of patient starts, and the number of hypersensitivity risk medications at any given time). The nursing allocation tool allowed for easily transparent color-coding to ensure that patient acuity was easily identifiable.
Following these measures, a go-live date was set and patients began arriving into the optimized templates on January 7, 2019. After feedback from the nursing and clinical treatment team following the initial go-live, templates underwent further optimization, with additional adjustments and modifications, and were implemented on March 11, 2019.

A period of 1/7/2019 – 6/1/2019 was compared to the same period of the prior year (1/8/2018 – 6/2/2018) to determine success of outcomes. All analyses were limited to weekdays, as no substantial changes were made to weekend templates.

Daily average completed appointments increased by 16.3% (or roughly 16 patients per day), while daily average scheduled hours increased by 9.63% (or roughly 29 treatment hours). Same-day add-ons increased by 38.9% (or roughly 1.5 patients per day).

It was important to follow several balancing measures to ensure that increases in utilization did not negatively impact patient care, and (despite the observed increases in utilization) chair wait time (or time between check-in and rooming) decreased by 14.5%, drug wait time (or time between rooming and first medication) decreased by 8%, and appointments running longer than expected decreased by 4.24%. No negative impacts to patient experience were observed.

Introduction: Intrathecal-targeted drug delivery is a therapeutic tool for managing intractable pain and spasticity. With this therapy, there is a need for a care coordination program to proactively and telephonically engage patients and caregivers to optimize therapeutic outcomes. Initially, the focus was on providing a one-dimensional approach to care coordination, focusing on chronic pain/spasticity issues related to patient care. However, through re-evaluation of the program and best practices in telephonic case management, gaps were identified as quality improvement opportunities. Commonly identified needs included potential emergent situations not related to chronic pain, patient crisis situations, customized telephone triage protocols designed to meet the needs of intrathecal pump patients, lack of patient resources and community support, lack of education regarding patient pain/pump therapy management, and the need for ongoing patient education and empowerment.

The program’s enhanced model aims to bridge the gap in intrathecal-targeted drug delivery therapy in order to provide patients with a comprehensive and holistic approach to maximize outcomes and provide robust value-added care.

Methods: Quality initiatives were successfully adopted. Actively participating patients with intrathecal-implanted pumps were offered an improved program model encompassing proactive telephonic nursing intervention and assessments, implementation of evidence-based clinical decision support tools customized to meet the needs of patients with intrathecal pumps, financial support services, health education, and community resources. Care coordination nurses were provided with ongoing education, training, and access to customized intrathecal telephone triage protocols in order to handle the unique disposition needs of patients treated with intrathecal-targeted drug delivery. A retrospective analysis of patients participating in the program was conducted after the implementation of the new model. Through case review, outcomes analysis, and patient engagement trends, the case management nurse team determined the unmet needs could be addressed through the incorporation of additional patient support and customized nursing interventions.

Results: Review of six months of program data demonstrates this customized phone-based care management program with a holistic approach proved beneficial. The engaged patient census grew 170%. Clinical outcomes analyses demonstrated 76% of patients had a positive perception of therapy effectiveness and quality of life. The improved care coordination model provides patients with multidimensional care to optimize outcomes.
Conclusion: The care coordination program implemented successful initiatives to collaboratively improve patient outcomes through implementation of the telephonic case management best practices and customized telephone triage protocols. The program has incorporated a comprehensive approach utilizing the biopsychosocial model. The study findings showed this new and improved model of the intrathecal care coordination program offers a more effective approach to providing holistic patient centered care; thus, improving the overall patient outcome and enhancing quality of life.

Significance/background: Oncology patients are at risk for malnutrition due to their diagnosis and treatment-related toxicities, which may prevent adequate calorie-protein intake for weight maintenance and require enteral nutrition (EN) support. Our NCI-designated cancer center uses a multidisciplinary, patient-centered team approach to provide oncology care for blood and marrow transplant (BMT) and general oncology (GO) patients, which is primarily delivered in the outpatient setting. Proactive medical nutrition therapy management and support is essential to keep patients successfully on treatment and prevent complications related to malnutrition.

With specialized training and privileges, registered dietitians (RDs) may place nasoenteric feeding tubes. A working group formed to create institutional practice to integrate RDs placing feeding tubes. Developing formalized institutional practice keeps staff trained and competent to place nasoenteric feeding tubes and minimizes barriers to timely referral and care coordination.

Purpose: To create a standardized workflow, which ensures RDs work to the top of their license to provide evidence-based nutrition support to oncology patients at risk for malnutrition and requiring nasoenteric feeding tube placement for EN support.

Intervention: After a historical chart review, our interdisciplinary team determined feeding tube placement incidence by disease group. The working group consensus was that the clinic-wide discipline responsible for feeding tube placement will be the RDs. Institutional policies, scope of service, and competency and training guidelines were created based on national recommendations. Education was instituted and implementation was jointly led by Nutrition (certified nutrition support clinician and RD manager) and nursing shared governance teams (clinical practice council and professional development council).

Discussion: Use of feeding tubes as a necessary component of oncology care is infrequent, yet essential for specific patients. The best practice model for delivery of services requires cross-professional analysis and delineation of roles/responsibilities. Nutrition support is foundational to the success of oncologic interventions and multidisciplinary teams are mandatory for the realization of efficacious implementation of clinical services. Routine referral to nutrition, orders for nasoenteric feeding tube placement, formula delivery, and follow-up will facilitate best patient care with each member of the multidisciplinary team functioning to the full of scope of licensure and practice.

Innovation/learning outcome: Staff practicing to the full scope of licensure resulted in RDs assuming responsibility for nasoenteric feeding tube placement with consistency in competency and confidence for best oncology patient outcomes.

Purpose: At a large NCI-designated ambulatory care cancer center, nurses play a vital role in coordinating the ongoing care and complex needs of patients. Functioning to the full scope of licensure, nurses’ responsibilities include complex care coordination, telephone triage, and patient education. Coordination of care necessitates accomplishment of many tasks including disability paperwork, patient-requested letters, insurance prior authorizations, and outside referrals, and often are deferred tasks. Balancing necessities of care coordination, clinic leaders and front-line staff recognized the opportunity to expand the practice of medical assistants to work to full scope of licensure. Development of new and expanded medical assistant (MA) roles have been identified in the literature as an opportunity to transform and improve workflows within ambulatory care clinics (Chapman & Blash, 2017). The purpose of this project was to evaluate the feasibility of imbedding a back office medical assistant (BOMA) into a disease-specific nursing team, with the goal of promoting effective and timely coordination of care.

Description: Clinic nurses were surveyed to capture current state and elements of care coordination tasks. Analysis of the data identified opportunities to reassess and distribute elements of care coordination for nurses and MAs. A team (a clinical nurse educator, a medical assistant supervisor, a nurse manager and several front-line nurses) convened to create a 6-week orientation pathway for the BOMA. The team identified important components of the orientation including documentation in the electronic medical record, communication pathways within the clinical team, and workflows for common care coordination tasks. Standard work documents were used as training tools and additional job aids were developed. A work space for the BOMA was created within the nursing workroom to facilitate communication and foster teamwork. To better understand disease-specific workflows, the BOMA was included in weekly nursing team meetings. Formal precepting was provided by the clinical nurse educator to ensure clinical knowledge and skill attainment. Four months after the implementation of the BOMA, the survey was repeated to evaluate efficacy and implications of this new role.

Evaluation/outcome: Evaluation of survey results demonstrated the addition of the BOMA role promoted efficient care coordination. Nurses surveyed reported the BOMA improved the team’s ability to provide effective and timely care to patients. The BOMA reported higher job satisfaction through this collaborative team environment as well as professional growth with the expanded responsibilities. Implementation of a dedicated disease-specific BOMA has provided a valuable resource to the clinical team. Analysis also revealed reduced deferment of tasks while also a positive trend of increased nurse ability to take dedicated breaks. The evaluation of the project successfully illustrated that functioning to the full scope of nurse/MA licensure improves care coordination and job satisfaction while strengthening collaborative teamwork. The implementation of disease-specific BOMAs will now be expanded into other clinical nurse teams throughout the institution.

References
1. Chapman, S. A., & Blash, L. K. (2017). New Roles for Medical Assistants in Innovative Primary Care Practices. Health Services Research, 383-406.
 

Background/purpose: The goal of palliative care (PC) is to prevent, assess, and relieve suffering through comprehensive symptom management and continued conversations regarding goals of care and quality of life. The fourth edition of National Consensus Project Clinical Practice Guidelines for Quality Palliative Care (NCP) describe eight essential domains and provide a template for delivery of this care in the community setting. Ambulatory care nurses are cornerstones of the interdisciplinary team from which primary palliative nursing care takes shape.

At our Magnet-designated comprehensive cancer center, we seek to address the eight domains of NCP and meet the needs of patients facing the serious illness of cancer by addressing the physical, psychosocial, spiritual, and emotional aspects of the disease. Nurses in our ambulatory care areas play a vital role in providing primary PC from time of diagnosis to death and advocate for referral to PC specialists to extend the reach of the offerings.

Description: To enhance delivery of PC, we adopted the COMFORTTMSM communication curriculum to broaden oncology nurses’ competencies to engage in difficult conversations in routine practice in the ambulatory care setting. We began with focus on the NCP domains of structure and processes of care, psychosocial and psychiatric aspects of care, and social aspects of care. The ambulatory care clinical specialist partnered with PC experts to offer classes with communication skills-building sessions and a communication toolkit, which included evidence-based patient decision prompts and palliative interview guides. Class time was also dedicated to debriefing and discussion to address barriers and concerns related to integration of COMFORTTMSM techniques into nurses’ busy clinic practices. To foster engagement, the curriculum was offered as part of nursing grand rounds and included as an element of advancement on the clinical ladder. Attendees were encouraged to adopt tools learned in the COMFORTTMSM curriculum to improve PC delivery in their clinics.

Evaluation/outcomes: The COMFORTTMSM communication curriculum became the inspiration for adoption of evidence-based practice to address NCP domains. Attendees from neuro-oncology clinic expressed concern for the social domain of PC and chose to adopt a question prompt list to assist their advanced cancer population in asking questions and making decisions about their care. Patient surveys indicated increases in questions asked during consultation by 50% and ease in discussing difficult issues by 39%. The head and neck and endocrine oncology clinic nurses implemented a patient interview technique known as BATHE to address the emotional needs of patients and families and incorporate the NCP domain of psychological and psychiatric aspects of care. Use of BATHE resulted in a 4% improvement in patient satisfaction scores for nurses’ concern for questions and worries.

We have successfully enhanced the delivery of palliative care in our ambulatory care setting through introduction of the COMFORTTMSM communication curriculum and adoption of tools and practices in diverse clinic settings. Ambulatory care nurses from all clinics are now encouraged to participate in COMFORTTMSM sessions and adopt care processes to address NCP domains of quality palliative care.

Background: Diabetes mellitus, type 2 (DM2) is a complex, chronic illness that requires both medical care and patient education to prevent complications (e.g., coronary heart disease, neuropathy, diabetic retinopathy). Myriad educational strategies have been utilized, including interactive dialog, written/print materials, computer-mediated options, group-based training programs, and self-help groups. Our safety net healthcare organization provides services for south Texas’ most socioeconomically disenfranchised population. Many are under-resourced (e.g., inadequate finances or insurance) and are often unable to use written materials (e.g., illiteracy, inability to read or hear, language barriers). Research demonstrates efficacy in teaching patients about other disease processes when innovative strategies (e.g., gamification) are used.

Purpose: The purpose of this evidence-based practice project was to explore the extant literature to determine what strategies have shown promise in promoting self-efficacy and self-care among persons with DM2.

Methods: Nurses working in an ambulatory care setting devised the following PICO question: What innovative technological pedagogies (I) or conventional teaching modalities (C) impact patient engagement in self-efficacy and self-care (O) among socioeconomically-disenfranchised patients with type II diabetes (P)? Nursing Reference Center Plus yielded 88 articles; 24 of these met specific inclusion criteria and were appraised by at least two members of the team. Incongruences were resolved by the entire team to reach consensus. A majority (n=14) of the articles were research, and 10 others were non-research papers.

Results: The literature is replete with citations supporting the importance of self-care in persons with DM2. Early involvement in self- or supportive-care by the patient and family demonstrated multifarious benefits. Educational modalities (e.g., 1:1 demonstration/return demonstration, group-based programs, mobile technology, gamification, communicating in a culturally-sensitive manner) have all shown promise in promoting self-care in this often-marginalized population.

Implications: It is imperative that nurses determine if individuals are auditory, visual, or tactile learners. Maybe they learn best by hearing, seeing, or doing a particular skill. Diabetes education can be comprehensive; therefore, it is vital to divide the teaching into segments that are congruent with the patient/family members’ ability to comprehend.

Conclusion: Patients’ understanding, involvement, and engagement are critical components in promoting self-efficacy and self-care in persons living with DM2. When individuals comprehend and adhere to the regimen, there are likely fewer complications and hospitalizations, and patient outcomes are enhanced.