August 29, 2016 | Tags: Blog | Tags: Team Based Care , CareOregon , Care Teams
Workforce projections in Oregon estimate “a 38% increase in additional primary care providers by 2030 to maintain the current rate of utilization” (Petterson, 2013). However, high-functioning teams that utilize registered nurses (RNs) to manage some conditions can help narrow this gap. Team-based care can increase staff and patient satisfaction while providing more focused meaningful care. Additionally, nurses have a unique skill set to leverage. The California Healthcare Foundation reported, “When RNs assist in the care of patients with chronic conditions, clinical outcomes for these patients improve compared with physician-only care.”
Enter: the Nurse Visit. Although definitions about nurse visits are not fully agreed on, there is some common language.
- Flip Visit: nurse begins visit with patient and then flips to provider
- Co-Visit: provider and nurse see the patient together.
- Independent Visit: nurse sees patient independently without a provider. Nurses have been using independent visits for a long time to address wound care needs and immunizations, for example.
- Protocol Visit: nurse has embedded protocol to assess and treat a patient independent of the provider using treatment guidelines
Nurse visits can morph from one type to another based on a patient’s care needs. For example, a nurse might begin a protocol visit as scheduled, but after assessing the patient realize the patient may require provider intervention. Due to this fluidity, scheduling can, at times, be complicated.
CareOregon led a Nursing Innovation Collaborative in early 2016 to support eight clinics in implementing nurse visits. Over the course of four months, clinics explored communication, data, documentation, training, billing, visit structures, provider perspectives, and team formation. In their final session, clinics discussed piloting and did a deeper dive on topics by request. Although each clinic progressed at their own speed and with their own unique implementation strategies, there were a few common lessons learned:
- Communicate, communicate, communicate.
- Your plan should be communicated with the entire team including the nurse, provider, MA, front desk staff, patient, etc. Communicate continuously and provide updates in whatever format is most effective for your team.
- Get the data. Use the data. Learn from the data.
- Determine what data you need. What kind of things are you changing for the patient? You might look at the 3rd next available appointment; how different outcomes are being affected; or even patient satisfaction. Once you pick your measures, continue to use that data to innovate further to find a nurse visit model that works for you.
- Train the nurse.
- Yes, we’ve been trained. There are nurses who have received significant training in a variety of nursing roles and skill sets. However, if the training did not include history taking and physical assessment and/or the nurse has not provided direct patient care in a primary care setting recently, then additional training is needed. It is important to talk to your nursing staff about their skills and determine where their barriers are, even if it is just learning to use the EHR in a different way.
- Communicate, communicate, communicate.
- I can’t say it enough. Make sure you communicate what’s going well, what’s not working, what you’d like to try differently, what you need to to improve, etc.
- Rinse and repeat.
Good luck implementing nurse visits as part of your transformation journey! Checkout the resources below to get started.
- Nurse Visits – A “Tasting” Flight of Visit Models Webinar: http://www.pcpci.org/resources/webinars/nurse-visits-tasting-flight-visit-models
- Bodenheimer, T.; Bauer, L.; Olayiwola, J.N.; and Syer, S. (2015) RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care. California Health Care Foundation
- Enhancing the Role of the Nurse in Primary Care: The RN "Co-Visit" (2015) The Journal of General Internal Medicine
- In the Incubator: Flip Visits (2014) Center for Care Innovations
- Dietzen, J.; Aguirre, J; and Oregon Primary Care Association. (2016). Best Practices for Documenting and Billing Non-Provider Vists - A Focus on RN Visits. *Information presented in this webinar reflects the individual presenter's experiences and does NOT represent their respective organizations.
- Petterson, SM; Cai, A; Moore, M; Bazemore, A. State-level projections of primary care workforce, 2010-2030. September 2013, Robert Graham Center, Washington, D.C.
- Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med 2015;13:107–14.
Charmian Casteel is a Primary Care Innovations Specialist at CareOregon has a great career in Nursing. She chose nursing in order to have a meaningful long term relationship with patients, focusing on health and well-being. Her career has been filled with fun positive experiences, especially since earning a Master’s degree in pediatrics. She has provided nursing care and leadership in school based nursing, research, family planning, DHS home visits, family practice, pediatric specialties, and nursing supervision. Living by the motto of reaching her greatest potential by helping others reach theirs led her to the role of Primary Care Innovations Specialist with CareOregon. Being part of a team of forward-thinking professionals in service to healthcare workers and patients state-wide has opened the shutters, windows, and doors to new relationships and an even more rewarding nursing career.