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very day, Dr. D felt exhausted by the end of a care session and wondered how much
longer she could survive double-booked appointments, paperwork, and charting. While
finishing her charting late each evening, she considered leaving.
J.C., one of the clinic’s RNs, spent all day phone-triaging patients who needed care
now but had no access. She wondered if her nursing skills were being used and valued.
She was tired of begging providers to double-book patients she felt should be seen.
She left most days without her work done, and though she loved the patients, she wondered
how long she could continue.
With more and more Americans gaining access to primary care, clinics face the challenge
of increasing demand for services with no enhanced capacity to meet the demand. The
tension that arises in such a system is exacerbated by provider and nurse burnout
and a recurring sense of under-providing healthcare. We addressed this issue by initiating
RN-led visits that required little provider time, thereby increasing access without
worsening burnout.
Clinica Family Health is a community health center with five clinical sites in communities
northwest of downtown Denver, Colorado. We serve approximately 45,000 patients annually,
with 98 % of our families living at or below 200 % of the federal poverty level. For
60 % of our patients, Spanish is the primary language, and virtually all of our providers
and staff speak English and Spanish. We have a long history of innovation in care
delivery, but by 2012, found ourselves struggling to sustain access with an eroding
base of providers.1 We decided to restructure our care delivery model in order to
maintain our success in achieving the triple aim, while increasing job satisfaction
among care team members.
Our goal was to increase access by modestly expanding panel sizes and enhancing the
team surrounding our providers. At the same time, we wanted to promote work/life balance
for care team members and inspire loyalty in order to retain physicians, nurse practitioners,
and physician assistants who were leaving for jobs with less pressure, more pay. We
started with a literature review and analysis of our existing pod model: 14 care teams,
or "pods," composed of medical doctors, nurse practitioners, physician assistants,
nurses, medical assistants, a case manager, a behavioral health provider, and operations
support staff. We evaluated each pod member’s role and scope. We completed time studies
on 34 visits prior to implementation, focusing on patient experience. We also interviewed
Clinica leaders and employees in other high-performing practices.
We learned through this process that we were not optimizing a hallmark of Clinica’s
care team transformation—utilizing each team member to better serve patients while
increasing joy in work. Of the 34 observed visits, only one involved a patient seeing
a nurse. Our nurses’ primary role had become phone triage, not direct patient care.
What’s more, a dearth of appointments had led to an uptick in triage calls. As one
RN explained it, “Triaging with no access creates only more work, electronic tasks
to finish, and extra phone calls… I hate telling patients to seek urgent care when
I know we could help them here if we had space…”
Through financial analysis, we determined that increasing total daily visits per provider
by appoximately 2 would achieve our access goal, while generating enough revenue to
cover the cost of additional care team staff. Yet adding provider visits was in direct
conflict with reducing provider burnout. Engaging our nurse colleagues in direct patient
care was a solution to this dilemma.2
In 2014, we tested an RN “flip visit” or co-visit in two pods through a pilot program
we called Pods 2.0. Co-visits address same-day acute complaints, and each nurse can
perform up to eight co-visits a day. During a co-visit, the nurse elicits and records
the history of present illness and past medical, family, and social histories. She
collects vital signs, implements pertinent standing orders, and creates a nurse note.
When the provider enters the room, the nurse presents the history to the provider
in front of the patient, allowing the provider to clarify details. At this point,
the nurse switches to a scribe role, documenting the provider’s physical exam, assessment,
and plan. After the provider moves on to the next patient encounter, the nurse reviews
the care plan and provides appropriate education with the patient. Later, the provider
quickly reviews and authenticates the visit documentation before submission for billing,
in accordance with Center for Medicaid and Medicare Services (CMS) guidelines.3
To staff the co-visits, we increased nursing full-time equivalents (FTEs) from 1.0
to 3.0 per pilot pod. We moved phone triage off the pod and piloted a triage-only
nurse position. We eliminated provider double-booking. Using detailed guidelines,
we layered in a separate nurse schedule for co-visits to be scheduled by a triage
nurse or by our centralized communication center. We added an extra medical assistant
to help with flow, medication refills and reconciliation, vaccine administration,
and other tasks. One nurse on each care team engaged in traditional nursing care such
as visits for patients taking warfarin, wound care, patient education, complex care
management, and quality outcome auditing. The other two nurses performed the co-visits
in conjunction with providers. The co-visit schedule ran in parallel with a provider
schedule featuring a slot held for one to two co-visits with the nurse partner for
every two standard visits completed by the provider (Fig. 1). Generally, flip visits
took 20–30 min total, requiring about 10 min of provider time. RNs found any available
provider on the care team to engage in co-visit care. Co-visits were used to provide
greater access to patients and could also help fill holes created in the provider
schedule by no-show patients. For the pilot, we “borrowed” staff from other care teams,
with the unfortunate consequence of leaving other teams understaffed.
Fig. 1
Sample care team schedule with RN co-visits. Grey areas represent blocked care slots
for co-visit consultation and catch-up charting
Careful preparation was essential for the co-visit model to succeed. We developed
a co-visit institute in which nurses, nurse practitioners, and physicians train nurses
how to appropriately document co-visits. In addition, nurses received instruction
on how to present patients effectively to their provider teammate. Finally, we helped
our providers learn how to support the nurse in accomplishing accurate and efficient
documentation. The Nursing Services Department developed scheduling guidelines for
call center staff and empowered nurses to schedule co-visits for appropriate patients
(e.g., those with acute complaints such as respiratory infections) and to designate
more complex patient complaints for provider appointments. Similarly, success of the
project depended on collaboration with our billing and coding team, electronic health
record experts, and compliance officer. We reviewed federal regulations on scribing
and state regulations on RN scope to ensure that our approach was compliant.
How did we do? At the first of two pilot sites, daily visit capacity increased by
17 %. At the second site, already a high-productivity facility, double-booked visits
were eliminated and capacity grew by 12 %. One provider who was fully booked at 12
patient slots in a morning was able to do three flip visits and bill for 15 patients.
Multiple care team members at the pilot sites reported improved satisfaction and work/life
balance based on surveys administered at the end of each pilot day. Some providers
reported leaving work on time with charting completed for the first time in years.
Nurses loved the new model, affirming that they felt valued and inspired to develop
their skills. Patient satisfaction for nurse co-visits averaged 9.5 out of 10, higher
than our baseline for provider visits. Since triage was removed from the pod, nurses
were able to directly assist patients.
Now, with the added capacity from the co-visit model translating into improved patient
access, we anticipate less triage demand. We plan to spread co-visits across our 14
pods in 2015, and will continue to assess whether the extra visits pay for additional
staff. With 14 care teams at Clinica, we plan to hire an additional 21 nurses across
the organization and an additional five nurses for triage, for a total of 26. Preliminary
business case analysis shows that a full year of Pods 2.0 staffing across all care
teams, at an average of 2 additional visits per day per medical provider, covers the
cost of all additional nursing and medical assistant staff and nets a modest positive
revenue.
By transforming Clinica’s RN role through the co-visit model, we are addressing seemingly
conflicting goals in primary care—patient access and workforce job satisfaction. By
honestly answering the question “Who is the best person on our care team to help you
with your problem today?,” nurse-led co-visits may be one answer to the complicated
issues facing primary care. By having RNs work at the top of their ability, we found
a way to improve access without increasing provider stress.