WelcomeAdvancing Team-Based Care

WEBINAR 3: The Emerging Role of Nurses in Primary CareMarch 31st, 2016

The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training

to interested health centers in: Transforming Teams• National Webinars on advancing team based care• Invited participation in Learning Collaboratives to advance team

based care at your health center

Training the Next Generation• Two National Webinar series on developing Nurse Practitioner

and Clinical Psychology residency programs and successfully hosting health professions students within health centers

• Invited participation in Learning Collaboratives to implement these programs at your health center

Email your contact information to nca@chc1.com and visit www.chc1.com/NCA.

Learning Objectives:

1. Participants will be able to name the ways in which nurses can be more fully utilized in improving outcomes for patients.

2. Participants will be able to identify the process for implementing independent nurse visits.

3. Participants will able to name two elements of complex care management.

Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and

#HRSAnca • Recording and slides are available after the presentation on our

website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca

The Emerging Role of Nurses in Primary Care:

Learning from Effective Ambulatory Practices

Community Health Center, Inc. and the MacColl Center for Healthcare Innovation

March 31, 2016

Margaret Flinter, LEAP Co-DirectorBrian Austin, LEAP Deputy Director

Why Primary Care Teams?

Improved clinical

outcomes

Better patient access

and experienc

e

Improved support

for complex patients

Reduced burnout

Become a recognize

dPCMH

30 LEAP Sites

Team Structure:Major Findings From Site Visits

Medical assistants, receptionists, and lay-persons play key patient care roles .

Roles are expanded. All staff work at the top of their license and skillsets.

All core teams supported by RN care managers, behavioral health specialists, pharmacists, etc.

Providers and their panels supported by core teams consisting of MAs, front desk, and others.

Primary Care Team

CentCoreTeam

Provider-MA

Teamlet

Provider-MA

Teamlet

Provider-MA

Teamlet

Extended Care Team

• Receptionist• Team RN• Health Coach• Panel Manager

• RN Care Managers• Lay Caregivers• Pharmacists• Behavioral Health

Specialists• Administrative Staff

RNs in 30 LEAP Sites

CentCoreTeam

Provider-MA

Teamlet

Provider-MA

Teamlet

Provider-MA

Teamlet

Extended Care Team

• On Core Team (13 Sites) – “Team RNs”

• On Extended Team (20) – “RN Care Managers”

• RNs on both (7)• No licensed nursing

staff (4)

Core Team RN Roles Observed• Panel management in conjunction

with primary care provider• Preventive, health promotion, and

chronic illness care management (in conjunction with primary care providers visits and independently)

• Daily schedule of nursing visits for acute, episodic, prevention, and chronic illness care under standing orders and delegated order sets

• Supervision, leadership and training of other team members

• Advice and triage, in person and by telephone

Core Team RN Roles Observed (continued)

• Additional core team RN roles and focus areas:– Hospital or SNF Transition

management – Leading or co-leading groups– Interdisciplinary team meetings– Medication reconciliation – Self management goal setting– Quality improvement activities– In some practices—complex care

management for subset of high risk/acuity patients

– Home visits

RN Care Manager Roles Observed• Complex care management of

subpanels of patients from multiple teamlets and teams– Defined criteria for admitting and

discharging from care management• Intensive transition management, in-

patient and post discharge– May include home visits

• Intensive coordination of community resources, directly or though an assigned case manager or community worker

• Intensive management of complex health problems often using delegated order sets

• Working with particularly vulnerable patients

Standing Orders and Delegated Order Sets• Standing orders: authorized by a licensed independent

health care provider and authorizes the RN to address, assess, and treat specific conditions across specific populations of patients, with recognition that patients who present with exceptions to the norm are referred back to a health care provider.

• Delegated order sets: established by a patient’s PCP for a specific patient to be carried out by the RN in visits between the patient and the RN based on assessment criteria.

Common Factors• Roles were clear, and all

operated to the top of their training/abilities

• PCPs were supportive and confident in RN capabilities

• Strong leadership support for prioritizing patient-facing RN roles

• Career ladders explicit, not just for RNs but all team members

• External and internal training in complex care management (IHI, OHSU)

• RNs had strong community ties and devoted time to community engagement

Investment and Resources• Nurses on core team varied as to

whether their organizations submitted billing for RN visits

– Medicaid coverage for RN visits seems to vary by state.

– Medicare has explicitly eliminated the “99211” nurse visit from payment in FQHCs.

• RN complex care managers funded by grants, ACOs, insurance plans, and sometimes by the practice itself

• Medicare coverage for transition management and care coordination were just beginning during the LEAP project

Resource Spotlight #1

Resource Spotlight #2

Community Health Center, Inc.

Foundational Pillars1. Clinical Excellence- fully Integrated teams,

fully integrated EMR, PCMH Level 3

2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students

CHC Profile:•Founding Year - 1972•200+ delivery sites•130k patients

The Role of the RN at Community Health Center, Inc.

At CHC, RNs are at the core of the primary care

team, trained and supported as complex

care managers, supporting

comprehensive health care services in a patient-centered medical home.

CHC Representatives: Mary Blankson, Chief Nursing OfficerSarahi Almonte, Nurse Supervisor

West County Health Centers

• Staff and Providers• 195 employees - 160 FTEs• 28 medical providers, 2 dentists, 16

behavioral health counselors and 1 psychiatrist

• Staffing Ratios relative to Provider• Front Office 1.75 : 1• MA 1.75 : 1• RN 1.2 : 1• BH 1 : 1• CHW 1 : 3

25

Relational Care

“It is much more important to know what sort of patient has a disease than

what sort of disease a patient has.”

-William Osler

RN Care Management• Transition Care• Complex Care Management• High Risk Disease Management• Care Coordination

MA Care Coordinator• Care Logistics• Simple Care Coordination• RN Support

Community Health Worker• Resource support• Barrier Reduction• Place-Based support

Behavioral Health• Focused Behavioral Health• Cognitive Behavioral Therapy• Addiction Support• Crisis support

PCHC Quick FactsFor you. For your family. For our community.

Largest, most comprehensive of Maine’s 19 CHCs

One of the largest of the 100 CHCs in New England

16 practice sites and service locations

Over 60,000 patients> 2/3 low income> 8000 uninsured> 3,000 on

Marketplace

Almost 400,000 patient visits

700 Employees (200 providers)

Over $2 million written off for sliding fee scale

$74 million budget – only 9% from HRSA grants

$44 million – salaries and benefits

Payer mix: MaineCare 26%, Uninsured 13%, Commercial 41%

Open Space for Discussion

RemindersSign up for our next webinar in this series:

Data Driven Dashboards to Support Team Based Care

Thurs., April 7th, 3–4 p.m. EST

Complete our survey!

Sign up at www.chc1.com/NCA

SpeakersFrom Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program Manager Mary Blankson, DNP, APRN, FNP-C, Chief Nursing OfficerSarahi Almonte, RN, Nurse SupervisorRamon Clarke, Medical Assistant

From MacColl Center for Health Care Innovation, Group Health Research Institute:Brian Austin, Deputy Director

From West County Health Centers:Jason Cunningham, DO, Agency Medical DirectorJymmey Purtill, RN, Clinic Nurse Manager

From Penobscot Community Health Care:Eric Perkins, RN, Nurse Care Manager