1. New Roles for RNs in Primary Care Panelists: Bernadette Thomas, Community Health Center, Inc., Middletown, CT Jacque Cobb, Eastern Oregon Medical Associates, Baker City, OR Molly 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

2. 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 Center 10:15 – 10:25 Comments and questions 10:25 – 10:30 Jacque Cobb, Eastern Oregon Medical Associates 10:30 – 10:40 Comments and questions 10:40 – 10:45 Molly Stevens, Martin’s Point Health Center 10:45 – 10:55 Comments and questions 10:55 – 11:00 What is next for LEAP? - Ed

3. Bernadette Thomas, APRN, DNP, MPH Chief Nursing Officer Community Health Center, Inc.

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

5. What is your innovative role? Primary Care Nurse Nurse Triage Special Populations: HCV, HIV, Suboxone Health care for the homeless Early detection program Patient Assistance Quality improvement Joint Commission content expert

6. 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

7. Training Experience Formal didactic training Lunch time webinars Grand round formats Local supervisors-managers

8. 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

9. Jacque Cobb, RN Oncologic Nurse Navigator St. Luke’s Clinic Eastern Oregon Medical Associates

10. 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.

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. Molly Stevens, RN, BSN Specialty Nurse Martin’s Point Health Care

17. 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

18. 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

19. 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

20. 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.

21. 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 responsibilities Anticoagulation therapy management Liaison with Community Care Team and Patient Centered Medical Home Post discharge follow up calls and assessments Participates on teams to evaluate and develop processes

22. Q&A and Closing Questions and Comments? Closing remarks – Ed

23. This webinar recording will be posted on the LEAP Commons website Connect on www.pctleapcommons.org