1. The Emerging Role of RNs in Primary Care: Population focused, person centered, nurse led
New Mexico Center for Nursing Excellence, June 11, 2018

2. And it takes a team to do this
New Mexico Center for Nursing Excellence, June 11, 2018

3. CHCI Locations in Connecticut
Federally Qualified Health Centers (FQHCs)
Nation’s largest safety net setting
Located in designated high need communities
Caring for 24 million patients annually
93% served are below 200% poverty and 35% uninsured
CHCI Profile
Founding year: 1972
Primary care hubs: 14; Sites: 204; Staff: 1,000
Patients/year: 100,000
Specialties: Onsite psychiatry, podiatry, chiropractic
Specialty access by eConsult to 20+ specialties
Elements of Model
Fully Integrated teams and data
Integration of key populations into primary care
Data driven performance
“Wherever You Are” approach to care delivery
Weitzman Institute
QI experts; national coaches
Project ECHO®—special populations
Formal research and R&D
Clinical workforce development
CHCI Foundational Pillars
New Mexico Center for Nursing Excellence, June 11, 2018

4. Center for Key Populations
Ryan White/HIV comprehensive services
Hepatitis C
Chronic pain
Opioid addiction
Healthcare for the Homeless
LGBT care
Maternal-infant/obstetrics
New Mexico Center for Nursing Excellence, June 11, 2018

5. “…stressed the importance of community engagement.
We want a consumer majority board… we are creating advocates to make sure questions are answered… accompany the patient to the hospital if need be.”
—Middletown Press, May 1972
New Mexico Center for Nursing Excellence, June 11, 2018

6. New Mexico Center for Nursing Excellence, June 11, 2018

7. Health Center Program: Impact and Growth
Over its 50 year history, the Health Center Program has grown from two health centers to nearly 1,400 health centers operating more than 11,000 sites in every U.S. state, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin.
Impact
For millions of Americans, including some of the most vulnerable individuals and families, health centers are the essential medical home where they find services that promote health and diagnose and treat disease and disability. In 2015, health centers employed nearly 190,000 people and served over 24 million patients. One in 13 people nationwide rely on a HRSA-funded health center for their preventive and primary health care needs.
Despite serving a population that is often sicker and more at risk than the general population, health center quality of care equals and often surpasses that provided by other primary care providers.
Over 93% of HRSA funded health centers met or exceeded at least one Healthy People 2020 goal for clinical performance in 2015.
More than 68% of health centers are recognized by national accrediting organizations as Patient Centered Medical Homes (PCMH)—an advanced model of patient centered primary care that emphasizes quality and care coordination through a team‐based approach to care.
Source:
New Mexico Center for Nursing Excellence, June 11, 2018

8. Objectives
Describe in depth the components of team based care: model, effectiveness, and role of care and extended teams
Identify focus areas for RNs in primary care and associated activities
Understand the use of clinical dashboards in advancing the health of populations in primary care
List benefits and challenges of a Primary Care DEU in undergraduate nursing education
New Mexico Center for Nursing Excellence, June 11, 2018

9. Why Primary Care Teams? Improved clinical outcomes
Improved support for highly complex patients
Opportunity to lower cost, increase safety
Better patient access and experience
Reduced burnout for providers and staff
New Mexico Center for Nursing Excellence, June 11, 2018

10. Major Findings From LEAP Site Visits
Team Structure:
Major Findings From LEAP Site Visits
Providers and their panels supported by core teams consisting of MAs, front desk, and others.
All core teams supported by RNs/RN care managers, behavioral health specialists, pharmacists, etc.
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.
New Mexico Center for Nursing Excellence, June 11, 2018

11. “Core” and “Extended” Team Members
Full-time (or close to full-time) individuals on a team that works with specific PCPs caring for a defined population of patients (a panel).
Extended:
Practice staff who have an ongoing professional relationship with the core team and who provide services to any patient of the practice or specific sub-populations.
New Mexico Center for Nursing Excellence, June 11, 2018

12. Every Patient Has a Team
New Mexico Center for Nursing Excellence, June 11, 2018

13. Community Care Teams: Beyond our walls
The “team” goes beyond the primary care practice/FQHC
New Mexico Center for Nursing Excellence, June 11, 2018

14. The Components of Integration
Evaluation
Training
Workflow/Process
Facilities/System
Leadership Structure
New Mexico Center for Nursing Excellence, June 11, 2018

15. Pod Design Supports Integration
New Mexico Center for Nursing Excellence, June 11, 2018

16. The Interdisciplinary Team
POD Design:
2 Medical Providers
1 Registered Nurse
2 Medical Assistants
1 Behavioral Health Clinician
Additional members: podiatrist, dietician, Pharm-D, chiropractor, CDE
Student/Trainees
New Mexico Center for Nursing Excellence, June 11, 2018

17. Key Elements of Success
All patients are embedded in a panel and assigned to a team
Defined and standardized documentation in the EHR
Training for existing and new staff to the standards
EHR registries, alerts, data
Integrated team/panel meetings
Accountability and reward
Recognition of impact
New Mexico Center for Nursing Excellence, June 11, 2018

18. Domains of RN Nursing Practice at CHCI, Inc.
Essential member of the primary care team and inter-professional activities:
(1) RN supports (2) primary care providers/panels
Key functional activities:
Patient education and treatment within provider visits
Independent nurse visits under standing orders
Delegated provider follow up visits using order sets
Self-management goal setting and care management
Complex care management; coordination and planning
Separate team: Telephonic advice and triage, managing high risk calls
Quality improvement leaders, coaches, and participants
Leaders and participants in research
Clinical mentoring of RN students; supervision and mentoring of medical assistants
New Mexico Center for Nursing Excellence, June 11, 2018

19. Nursing Standing Orders
Uncomplicated UTI
Vulvovaginal candidiasis
Comprehensive diabetes visit with retinal screening
Pupil dilation
Titration of basal insulin
Pediatric and adult vaccines
TB DOT
Bronchodilator testing in spirometry
Tobacco cessation
Emergency contraception
Pregnancy testing
Orders for emergency situations
Not sure if we use this slide???
New Mexico Center for Nursing Excellence, June 11, 2018

20. Order Sets
New Mexico Center for Nursing Excellence, June 11, 2018

21. Chronic Illness Care
New Mexico Center for Nursing Excellence, June 11, 2018

22. Independent Nursing Visits: 12 months
New Mexico Center for Nursing Excellence, June 11, 2018

23. Data underlies Panel Management: PCPs
New Mexico Center for Nursing Excellence, June 11, 2018

24. MA Planned Care Dashboard
New Mexico Center for Nursing Excellence, June 11, 2018

25. RN Complex Care Management Dashboard: Eligible Patients
New Mexico Center for Nursing Excellence, June 11, 2018

26. Behavioral Health Dashboard
Rethinking the warm hand-off process: Proactive vs Reactive
Medical initiated warm hand-off and behavioral health initiated warm hand-off
Criteria:
No BH services and PHQ above 15
No BH services and BH Diagnosis
No BH services and chronic pain patient
New Mexico Center for Nursing Excellence, June 11, 2018

27. Behavioral Health Integration Dashboard
Planned Care in Behavioral Health
Delivery of Integrated Services
New Mexico Center for Nursing Excellence, June 11, 2018

28. Medicare CCM
Goal: RNs will enroll eligible patients in Medicare Chronic Care Management (CCM), perform Social Determinants of Health (SDOH) screen, and document a comprehensive care plan utilizing tools in the Electronic Health Record (EHR), eCW.
New Mexico Center for Nursing Excellence, June 11, 2018

29. RNs Manage transitions of care for all patients
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New Mexico Center for Nursing Excellence, June 11, 2018

30. SO: How do we prepare the next generation?
Academic curricula for baccalaureate nursing students may not include focus on:
Primary Care Role of RNs
Competencies for primary care practice
Population Health and underserved populations
Potential primary care clinical sites may not be practicing in a team based model with:
Clear RN roles, competencies, and authority
Accountability and Recognition
Nursing leadership to support team based care
New Mexico Center for Nursing Excellence, June 11, 2018

31. The Primary Care Dedicated Education Unit
DEUs have been used successfully for years to support BSN student clinical experience in the hospital setting. Can this be transferred to primary care?
CHCI’s HRSA funded (NEPQR) project included implementing an RN Primary Care DEU at CHC with long- term partner, Quinnipiac University School of Nursing, to:
Capitalize on Experiential Learning
Involve CHC RNs preceptors and content experts
Engage QU faculty to assist with knowledge integration
Defined competencies for BSN students in primary care
New Mexico Center for Nursing Excellence, June 11, 2018

32. DEU Implementation YEAR 1 YEAR 2 YEAR 3 16 students total
8/8 for 7 weeks each
Opposite 7 weeks with homecare
Preceptor-to-student ratio = 1:2
Developed competencies
Utilized Recall Lists to identify additional student experiences
YEAR 2
16 students
12 weeks
Expanded sites
Nurse Managers as DEU faculty
Preceptor-to-student ratio = 1:1
Implemented competencies
Added formal post conference
YEAR 3
32 students
16/16 for 6 weeks (50/50 Model with Simulation)
Expanded DEU to other schools/sites
Expanded Faculty
Refined competencies
Preceptor Training
Implemented Student Coordinator
New Mexico Center for Nursing Excellence, June 11, 2018

33. Training Everyone to a New Model of Care
Weekly, distance, case-based learning for RNs engaged in complex care management with a team of experts in nursing, medicine, BH, pharmacy, social services, nutrition of patients in chronic Pain, HIV, Hepatitis C, pediatric behavioral health, and opioid addiction treatment.
New Mexico Center for Nursing Excellence, June 11, 2018

34. CHCI PC RN Role QSEN DEU Competencies AAACN CCTM Curriculum
Quality & Safety education for nurses
AAACN CCTM Curriculum
New Mexico Center for Nursing Excellence, June 11, 2018

35. QSEN DEU Competencies Knowledge/Skills/Attitudes
Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
Quality & Safety education for nurses
New Mexico Center for Nursing Excellence, June 11, 2018

36. BSN Student Focus Groups
Understanding the role of the Primary Care Nurse
“I’ve done ten-fold more patient education here than I ever had on a hospital floor”
The nurse was “not treating the diagnosis” but “treating the whole person”.
Interdisciplinary Care Team
It amazed them to observe “each pod and seeing how they work together as a team” and communicated so well across disciplines
Exposure to diverse patient populations
“There are a lot of vulnerable populations that attend the community health centers, and seeing that they are treated equally and given the same support and care as they should be is really awesome.”
New Mexico Center for Nursing Excellence, June 11, 2018

37. Next Steps Expanding the DEU to more clinical sites/partners
Collaborating with academic institutions for curriculum re-design to include more focus on primary care
Contribution to Simulation around Key Populations and Complex Primary Care
Dissemination of data from past three years
Mary
New Mexico Center for Nursing Excellence, June 11, 2018

38. Training everyone on the “next generation” team
CHCI’s postgraduate NP Residency Program for new family NPs and Psychiatric/ Mental Health NPs
CHCI’s postdoctoral clinical psychology residency program
National Institute for Medical Assistant Advancement (NIMAA)
Administrative Leadership Fellowship
Center for Key Populations Fellowship
300 students of all the health professions
New Mexico Center for Nursing Excellence, June 11, 2018

39. Contact Information
Margaret Flinter, PhD, APRN:
Mary Blankson, DNP, APRN:
Kerry Bamrick, MBA: (health professions training)
Veena Channamsetty, MD:
New Mexico Center for Nursing Excellence, June 11, 2018

40. Workshop focus areas:
Develop a global aim statement for preparing BSN students for roles and positions in primary care. Identify challenges and strategize on approaches to: 1) developing partnerships with high performing primary care practices 2)developing/expanding nursing faculty primary care competencies 3)devoting curriculum to primary care specific content 4)making the case for creating a DEU in one of your partner sites Based on your current knowledge and engagement in primary care, population health, and value based plans, create a business case for investing in a BSN workforce in primary care