Redesigning Care Delivery to Define the Ambulatory Care Nursing Role

Background: The role of nursing in ambulatory care has historically been ambiguous. AAACN’s recently revised position statement provides a framework to guide organizational approaches to effectively utilizing registered nurses in this environment. Numerous barriers exist to implementing the recommendations in current practice.

Purpose: This presentation will describe our approach to enhancing the registered nurse role in a multi-specialty, multi-site, provider-practice group organized around an independent-provider practice model. Application of transformational and servant leadership theories to effect practice change in a project of this scope will be discussed.

Methods: Our organization employs over 400 providers and 278 clinical staff at over 70 sites, including 159 registered nurses. Prior to this initiative, clinical roles and staffing model varied across sites regardless of panel acuity, and individual sites varied in the extent and mode of implementation of the RN care coordinator role. Inconsistencies in documentation revealed lack of standards for data collection. Further, no empirical data existed to quantify care-coordination activities, and staff interviews revealed wide variation in workflows from site to site. Beginning with primary care sites, nursing leadership collaborated with operational and medical leadership to standardize workflows including pre-visit prep, office visit intake, hospital follow-up, complex care management, and panel management. A staged roll out to individual sites is utilized with onsite practice coaching and education. Informatics tools were acquired or enhanced to establish and automate workflows and to organize tasks by patient complexity. Implementation is ongoing, with 8 primary care sites currently engaged and plans to expand to the remaining 11 sites by the end of 2019.

Results: This process has produced data that describes clinical tasks across defined patient populations. Our hospital follow-up (HFU) program serves as an example: since implementation, 873 patients have been enrolled in the HFU program at discharge, with 278 scheduled for follow-up office visits; 75% of which were scheduled within the 7-day timeframe instituted in our new workflow; 10 additional process-level data points exist for this HFU program. A total of 26 data-points are now available across 3 workflows to measure care coordination activities. Similar process-specific data is available for each workflow and will be reviewed. Measurement of clinical outcomes is in development.

Discussion: Through the implementation of informatics tools to stratify patient acuity and drive workflow, care coordination activities are identified for both low- and high-complexity patients. This clarifies the RN care coordinator role to include high-risk care coordination activities, care management, and facilitation of practice panel management. By defining and providing a means to measure rooming and pre-visit activities for non-complex patients, a framework for a medical assistant role is established. This creates the opportunity to define a nursing role for the RN and LPN for the remainder of care coordination and care planning for moderate-complexity patients.