You are here:--Dream teams

Dream teams

When it comes to care coordination, economy of scale, quality outcomes and best practices, ambulatory nurses are in the vanguard of care in our changing healthcare environment.

Ambulatory nurses throughout the country talked with about their roles, programs they’ve created to meet the complex needs of patients, the challenges they’ve faced and how they’re empowering patients to be partners in their own care.

Coordinators team up

Janet Fuchs, RN

Improving interdisciplinary communication and care coordination and getting patients more involved are challenges Janet Fuchs, RN, MSN, MBA, CNS, NEA-BC, associate CNO for ambulatory practice at Cleveland Clinic, has been working on with her team. “It’s the nurses functioning as care coordinators, along with the healthcare team, who are key to the management of the patients’ needs,” said Fuchs, who is chairwoman of the health policy committee for the American Academy of Ambulatory Care Nursing.

At Cleveland Clinic, there are more than 180 care coordinator RNs who see high-risk patients in the primary and specialty care clinics and provide care to them across the healthcare continuum, from the ambulatory clinic to the hospital to the home and to extended-care facilities. “We’ve been doing care coordination for years, but recently we have focused on further differentiation and development of the role of the care coordinator,” Fuchs said. “There has been an emphasis on developing team-based care, which allows us to utilize staff to the peak of their licensure.”

The team uses the EPIC EMR to identify healthcare team members across the continuum and has developed a section for team notes and patient registries to monitor patient progress and goals. They also have educated staff about care coordination and health coaching so patients are engaged in their own healthcare, Fuchs said.

“We are seeing a number of high-risk patients with complex needs,” Fuchs said. “In the primary care setting, this might be a patient with multiple comorbidities, polypharmacy, a lack of support within the home or a history of homelessness, or alcohol or drug addiction.”

New approaches to complex cases

Patients with high-risk conditions, such as a transplants, now are cared for in specialty clinics at Cleveland Clinic. The care coordinators collaborate with patients and their families from pre-transplant, postoperatively and often throughout their lifetime. Because of the demands of the role, Fuchs said the clinic looks for care coordinators who have experience, can think critically and have the ability and maturity to communicate with all team members.

The RN coordinators help patients take ownership through goal-directed processes. For transplant patients, for example, they have created customized education about what to expect after surgery and a teach-back program for caregivers who provide wound care and administer medications postoperatively.

“We’re also working to develop care systems focused on patient-centered care so that when patients call in with questions to the RN coordinators, they know that they will hear back from that person,” Fuchs said. “This approach facilitates and supports our patient-centered care model.”

At the clinic, staff is measuring and documenting patient outcomes, such as patient satisfaction, length of stay and compliance with quality indicators for high-risk patient populations.

Helping high-risk patients

Anne Jessie, RN

At Carillon Clinic in Roanoke, Va., which provides about 43 patient-centered medical homes and 60 specialty clinics, RN care coordinators have helped answer the need to identify high-risk patients, transitioning them from the inpatient or outpatient settings to appropriate services and providing followup to prevent or avoid gaps in their care.

“When we look at our patients’ acute care needs and how we’re going to respond to them, we need to ensure that we consider the whole patient and their individual care preferences, including not only their clinical needs but their psychosocial needs as well.” said Anne Jessie, RN, MSN, senior director of ambulatory practice, who sees the often unexpected and episodic nature of ambulatory care as a challenge. “Patients call us or come to us with symptoms that may range from a cold to a life-threatening illness, and we have to use our assessment and critical thinking skills to determine where they need to go for appropriate care.”
To address the challenges of life-threatening illnesses, the clinic is piloting a program for patients with heart failure.

“If a patient with heart failure is discharged from the hospital and at the time doesn’t qualify for home care, they receive one cost-free transition visit from a home health nurse, who assesses the patient’s needs at home and determines whether he or she qualifies for any services,” said Jessie, who is is a member of the AAACN’s Leadership Special Interest Group and the RN care coordination and transition management project.

Engagement and interaction

Jessie credits ambulatory care nurses with developing long-standing patient relationships, engaging patients in proper self-care management and providing them with the information and skills they need.

New to the organization is the patient portal called “My Chart,” in which patients receive information and may request additional information through a secure email system integrated within the EMR system. This service is offered along with onsite educational sessions and one-on-one education.

The team also is piloting the extensivist model to coordinate care for its more critically ill patients, such as patients in the neurology movement disease center.

Similar to the intensivist/hospitalist inpatient model, there is a multidisciplinary team, including an RN coordinator, physician, pharmacist, behaviorist, dietitician and OT/PT, who have laboratory and X-ray services available and care for patients.

“It’s team based and everyone comes together to develop and implement a plan of care with the patient and the family,” Jessie said. “We are seeing the ‘whole’ patient.”

Essential to ambulatory care is an integrated EMR, where interdisciplinary providers can access the patient’s plan of care and identify disease-specific orders.

With the integrated EMR, Jessie envisions inpatient and ambulatory care coordinators partnering up and using patient-specific education modules that build upon one another and are based on the patients’ needs. Progressing through the healthcare continuum, the patient would continue to develop their knowledge and skills with regular assessment and feedback from providers.

Growing and changing roles

Kathy Mertens, RN

Because of the shift to wellness and prevention, Kathy Mertens, RN, MN, MPH, assistant administrator and director of ambulatory nursing at Harborview Medical Center in Seattle, said it’s a perfect time to be an ambulatory care nurse.

“We get to see our patients for the long term and work with them to improve their health and well-being,” said Mertens, who has been working with nurses and interprofessional colleagues to implement a patient-centered medical home model in primary care clinics.

Serving socially and medically vulnerable populations, Harborviews’ more than 55 primary and specialty service clinics see more than 250,000 patients a year, Mertens said.

“We’re caring for patients with complex medical and social needs and without adding resources, so we need to provide smarter and more efficient care that is targeted to the patient’s specific needs,” she said.

With that in mind, she and her colleagues are piloting a team model in some of the primary care clinics. The RN care manager works collaboratively with an NP, consulting MD and a psychiatrist in the care of high-risk patients. The team formulates weekly action plans and patients meet by phone or in person to discuss their treatment plans and goals with the RN care manager. “Our patients don’t fall through the cracks, and we work actively with them at least weekly, or more, depending on their needs, involving social work and other professionals as needed,” Mertens said.

The patient portal also has provided the team with an effective way to engage patients by allowing them to see test results and a summary from their last visit and allowing them to message team members with questions or concerns.

More than 20% of the patient visits require telephone or in-person interpretation and staff-use video interpretation sometimes, said Mertens, who was part of the expert panel that developed the AAACN core curriculum published in May. The AAACN core curriculum focuses on care coordination and transition management. One of the key domains of the curriculum is patient and family engagement.

New model of care

Diane Resnick, RN

In 2011, the Harborview Medical Center opened a medical respite program, which is a 34-bed, medical care unit for patients who need care but have nowhere to go. Called the Edward Thomas House, it is a community and hospital partnership that decreases hospital readmissions and helps vulnerable patients transition to the community.

A majority of these patients require medical care, whether it be wound or postop care and may have exacerbated chronic illnesses or chemical or drug dependence.
“They don’t meet our inpatient criteria, but are too sick to go back to the street or to a shelter to receive care in one of our ambulatory care settings,” said Mertens, who explained that nurses are there 12 hours a day to administer medications and provide physical care and education. Professional staff also are on hand to provide chemical and mental health treatment and help in locating housing. Two mental health specalists and a security guard are on night duty.

“As ambulatory care nurses, we’re doing what we’re meant to do,” said Diane Resnick, RN-BC, MPA, manager of the Jane H. Booker Family Health Center at Jersey Shore University Medical Center in Neptune, N.J., and a member of the Meridian Health family. “Rather than sending patients home right after hospitalizations, we’re making sure they transition from the hospital back to the primary care office for follow-up care, wherever needed. We’ve always involved our patients in their care, but now we’re proactive in helping them understand the steps they need to follow. We’re leading the way and empowering patients as partners.”

At the heart failure center, nurses communicate via telephone to make sure patients with heart failure are staying on target with their weight and medication compliance. Patients who are identified as high-risk also receive follow-up appointments before being discharged from the hospital and medical residents schedule “transition of care” appointments within three days after discharge to ensure patients continue with their care. Patients are called if they miss appointments by medical residents who have established relationships with the patients while they are hospitalized.

Nurses and NPs also contact Medicare patients who were hospitalized within two days of their discharge to ensure that medications are reconciled and that patients have a clear understanding of their next steps in their plan, such as completing lab work or following up on appointments.

Sustained relationships

In the center’s NP-run pediatric asthma clinic, Patricia Lucarelli, RN-BC, MSN, CPNP, APN, PMHS, works one-on-one with patients and their families giving them asthma education and control over their care, which resulted in a 96% decrease in ED visits in its first year, said Resnick, who is chairwoman of the Leadership Special Interest Group of the AAACN. In its third year, the clinic has sustained positive outcomes, now showing zero ED visits for these patients. The center treats those with Medicaid, Medicare or no insurance as well those on charity care.

Resnick said the team faces challenges such as patients who may not have consistently working phones, making it difficult to reach them, or transportation issues that make it difficult for patients to show up for appointments. For patients with language barriers, Resnick said telephone and onsite interpreters help ensure patients understand what they are taught and using a teach-back method also empowers patients to sustain their care at home.

The program’s success revolves around the team-based, interactive approach, and the use of the Plan-Do-Study-Act method, a performance improvement project that focuses on education needs assessments, treatment plans, follow-up care and education.

The center’s ambulatory nurses see patients and their families grow up, caring for them for 20 years or more. “This is what makes ambulatory nursing so unique,” Resnick said. “We can guide and engage patients at different stages of their lives based on their immediate needs, and it is so gratifying to know that we have made a long-term impact on people’s lives.”


CE Subscriptions Built for Your Convenience!

750+ ANCC-accredited courses. 2 subscription options. CE that
meets your needs.

By | 2021-05-07T08:53:00-04:00 June 9th, 2014|Categories: Nursing Education|0 Comments

About the Author:


Leave A Comment