Taking ACTION: Optimizing Ambulatory Care Practice Models

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.