New Roles for RNs in Primary Care

Panelists:Bernadette Thomas, Community Health Center, Inc. , Middletown, CT

Jacque Cobb, Eastern Oregon Medical Associates, Baker City, ORMolly Stevens, Martin’s Point Health Center, Bangor, ME

Moderators:Amy Hardy, Central City Concern, Portland, OR

Ed Wagner, MacColl Center for Health Care Innovation, Seattle, WA

Host:Judith Schaefer, MacColl Center for Health Care Innovation, Seattle, WA

Learning Community Webinar #6

May 7, 2014 10:00-11:00am Pacific

New Roles for RNs in Primary Care Agenda: 10:00 – 10:05 Open the webinar, instructions, and overview of the agenda – Judith Schaefer

10:05 – 10:10 Welcome– Ed Wagner/Amy Hardy

10:10 – 10:50 Panelist presentations and discussion - Moderator – Amy Hardy

10:10 – 10:15 Bernadette Thomas, Community Health Center10:15 – 10:25 Comments and questions

10:25 – 10:30 Jacque Cobb, Eastern Oregon Medical Associates10:30 – 10:40 Comments and questions

10:40 – 10:45 Molly Stevens, Martin’s Point Health Center10:45 – 10:55 Comments and questions

10:55 – 11:00 What is next for LEAP? - Ed

Bernadette Thomas, APRN, DNP, MPHChief Nursing Officer

Community Health Center, Inc.

Innovation

• Expanded scope of nursing practice– Direct patient care– Investment in expanded scope• Clinical care• Management • Quality Improvement• Leadership

What is your innovative role?

Enhancing care delivery• Independent nurse visit by delegation• Independent nurse visit by standing order• Triage• Panel management• Abnormal cancer screening• Retinopathy• Care coordination• Medication administration• Management and supervision

Training Experience

• Formal didactic training• Lunch time webinars• Grand round formats• Local supervisors-managers

How does your role work within the team?

• Team time: huddle, panel management• “Blocked” time– ECHO– Care Coordination

• Managers’ time• Non-direct patient care roles

Jacque Cobb, RNOncologic Nurse Navigator

St. Luke’s Clinic Eastern Oregon Medical Associates

Innovation• How is your role different than the traditional RN role in ambulatory care.

– Cancer care – Adaptable to other specialty populations. – I take patients from diagnosis through the cancer care continuum

(biopsy, surgery, chemotherapy, ect.) and transition to hospice if needed.

Examples– Co-visit when a patient is diagnosed with cancer

• evaluation of the patients needs and• provide further education. They leave the visit with a care plan

– Guide patients through the biopsy process, and on to surgery if

needed.

What is your innovative role?

• What tasks do you perform now?– I am a Nurse Navigator, Infusion Nurse, Coumadin

Clinic Nurse, Primary Nurse (rooming patients for the Oncologic Nurse Practitioner when she flies in from Boise, completing co-visits with her and patients)

– I network with the community resources and the local hospital to facilitate care throughout the community

Innovative role

• How does it fit within the patient flow?– When I am needed to navigate, I complete tasks in

between patients appointments in my other roles. If I am needed for a co-visit, the provider and I work on a mutual time when we are both in the clinic.

– I work with the entire community affected by cancer. I am the resource for questions and concerns from any person or family member affected by a new diagnosis.

Enhancing care delivery

Guide and support patients through their cancer journey

–Direct contact to call with questions–Providers trust that the patient will be moved through the process without them being heavily involved, I give the provider regular status updates on the patient–We are currently gathering data on colon cancer from the time of diagnosis to treatment, with and with out a navigator. Time was cut in half with a navigator being involved.

Training Experience

– I created this role, in partnership with Mountain States Tumor Institute. They had not previously had a general navigator in a rural community.

– Specific background in cancer care both in endoscopy/colonoscopy and chemotherapy administration

– Training in Chemotherapy and Biotherapy along with cancer basics

– Family practice experience working with all the current PCP’s as a team nurse, giving me the credibility and a strong working relationship.

How does your role work within the team?

– Assistants and other RN’s refer to me when they have a patient or family with cancer related concerns or questions.

– Navigation itself takes 2-4 hours a week, this does not include co-visits on appointment days.

– Much of my time is on the phone following up with patients and family. This time is not protected time, however, my other clinic schedules allow for adjustment if the time is needed.

Molly Stevens, RN, BSNSpecialty Nurse

Martin’s Point Health Care

Innovation

• RN/provider offer collaborative care for our most chronically ill patients

• Patient pre visit activity• Integrates RN skills into the patient visit (RN conducts

majority of patient visit)• Collaborates RN/Provider roles during the patient visit• Enables RN to appropriately care for the most chronic

of our patients

My Innovative Role

• Comprehensive view of patient with chronic disease– Prior to visit review of patient status and

discussion/planning with provider– Hour long collaborative office visits

• Goal setting, shared decision making with patient, review quality measures and protocols, review lab/test results, education

– Between visits – follow up contact with patient– Follow up with patients after hospital discharge– Some case management and liaison with outside agencies

Enhancing care delivery• Improvement in quality outcomes

– Diabetic patients in poor control who had collaborative visits outperformed diabetics in poor control who were under the traditional care model in categories of A1C, BP and LDL at target.

• Improved revenue – increased RVU/provider per hour– 15 minutes of provider time for a visit coded at 99214, 99215

• Decreased costs - lower per member per month costs for ED/inpatient expenses despite higher cost of care in our region

• Increased patient satisfaction – high loyalty scores and retention rate

• Increased provider/RN satisfaction - 100% satisfaction

Training Experience• Clear and transparent training program that includes deliberate feedback

to develop and refine competencies, processes and protocols• Training for the specialty nurse in:

– Case management– Coaching – motivational interviewing, appreciative inquiry, etc. – Optimal utilization of electronic medical record (both practice and

Health Information Exchange)– Diabetes management and other chronic conditions– Population Management – Coding

• Ongoing feedback and evaluation of process – RN/Providers and practice leadership conduct biweekly meetings.

How does your role work within the team?

• RN has her own schedule of patients shared with provider for collaborative visits• Time blocked for administrative tasks and pt follow up

Other responsibilitiesAnticoagulation therapy management Liaison with Community Care Team and Patient Centered Medical HomePost discharge follow up calls and assessments Participates on teams to evaluate and develop processes

Q&A and Closing

• Questions and Comments?• Closing remarks – Ed

This webinar recording will be posted on the LEAP Commons websiteConnect on www.pctleapcommons.org