Ancillary Support to Achieve Nursing Top-of-License Practice

In 2010, The Institute of Medicine (IOM) published a report, The Future of Nursing: Leading Change, Advancing Health. This report outlined several recommendations that would allow for nurses to contribute to the improvement of patient outcomes and the healthcare system in general. One of the recommendations was that “nurses should practice to the full extent of their education,” meaning to work at the top of their license (TOL). In recent years, nurses have been tasked with providing more patient-centered, efficient, and cost-effective care. To meet these demands in a healthcare environment that consists of higher patient acuity and complexity, a nursing shortage, and significant fiscal constraints, nurses must be allowed to focus on tasks that require their unique knowledge and training.
Literature suggests that to achieve TOL practice, healthcare processes must be redesigned to identify tasks vital to nursing care and other activities that should be redistributed to nursing support staff. Summit Health provides coordinated care across urgent care, primary care, and multispecialty practices with more than 2,800 providers and 13,000 employees in over 370 locations in New Jersey, New York, Connecticut, Pennsylvania, and Oregon. The organization is expanding rapidly, requiring innovative approaches to delivering care and improving patient outcomes. This pilot’s purpose was to identify tasks that could be managed by support staff and enable registered nurses to work to the top of license.
The first initiative was to improve the management of medication prior authorizations. A unit was established to complete prior authorizations for the three service lines, reduce denials and appeals, and allow more time for the clinical team members to focus on provider support, interprofessional collaboration, care management, telephone triage, and patient education. The first step was to determine how many prior authorizations were being completed each month across the three service lines (1,200). We then assigned two support staff to focus completely on the prior authorizations and determined that one person could manage approximately 200 prior authorizations a month. We staffed a prior authorization unit with six people and did the following: 1)had each team member train in each individual service line; 2)created a standardized procedure for requesting prior authorizations, managing denials, and managing appeals; and 3) developed a pathway to route all prior authorization to that team in the EHR.
Over the past eleven months, authorization denials decreased by approximately 7%. Of those denials, only 0.25% required appeals. Urgent prior authorizations are completed in 72 hours and standard requests are completed in seven to ten days. Clinical time gained from this initiative is focused on quality improvement. The nurses are developing telephone triage protocols and collaborating with their clinical teams to create reference binders for new hires and the float team. Endocrinology nurses are developing a diabetes protocol to track patients who receive insulin dose adjustments. Most importantly, nurses have reported greater job satisfaction and patients are received their medications in a timelier manner. We received an innovation award for this initiative and have begun expanding this model to other service lines.