Introduction: The Role of the Registered Nurse in the Primary Care PCMH Setting

Susan Thorn, RN LNCMasters in Organizational Management

Agenda Day One Reflective Pause Welcome The Chronic Care Model AAACN Standards of Practice Triage and Decision Making: Part One Lunch Triage and Decision Making: Part Two Quality: Activities, Outcomes, and Data

Reflective Pause

The Chronic Care Model • Ed Wagner: The Father of Chronic Care

• “The current care systems cannot do the job”

• “Trying harder will not work”

• “Changing care systems will”

• The Chronic Care Model Talk

http://www.improvingchroniccare.org

The Community: Resources and Policies • Mobilize community resources to meet needs of patients• Encourage patients to participate in effective community

programs• Form partnerships with community organizations to support and

develop interventions that fill gaps in needed services• Self-Management Support

– Motivational Interviewing

– Diabetes Education

– Chronic self-care management

Health Delivery System Design: PCMH • Assure the delivery of effective, efficient clinical care and self-

management support• Define roles and distribute tasks among team members• Use planned interactions to support evidence-based care• Provide clinical case management services for complex

patients • Ensure regular follow-up by the care team• Give care that patients understand and that fits with their

cultural background

Decision Support

• Promote clinical care that is consistent with scientific evidence and patient preferences

• Embed evidence-based guidelines into daily clinical practice• Share evidence-based guidelines and information with

patients to encourage their participation• Use proven provider education methods• Integrate specialist expertise and primary care

Electronic Data Systems

• Organize patient and population data to facilitate efficient and effective care

• Provide timely reminders for providers and patients• Identify relevant subpopulations for proactive care• Facilitate individual patient care planning• Share information with patients and providers to coordinate

care (2003 update)• Monitor performance of practice team and care system

The Current Problem…

• Rushed practitioners not following established practice

guidelines

• Lack of care coordination

• Lack of active follow-up to ensure the best outcomes

• Patients inadequately trained to manage their illnesses

• Right staffing models for chronic care

Enter the Registered Nurse!

RN Scope and Standards of Practice

American Academy of Ambulatory Care Nursing

Goals and Objectives

• Definition of Professional Ambulatory Care

• Evolution of current ambulatory care and nursing practice

• The Practice environment

• The Science and Art of Ambulatory Care

• Ambulatory Nursing Roles

• Review of Standards

Overview

• First published in 1987

• Ambulatory Care is considered a specialty

• Ambulatory care nursing is dynamic

• Revisions to standards in 2009 through task force

• Six Standards address the six phases of the nursing process

• Ten Standards address professional performance

Definition of Professional Ambulatory Care• Unique domain of specialty nursing

• Individuals, families, groups, communities, and populations

• Primary care

• Specialty care

• Non-acute community outpatient

• Telehealth

Conceptual Framework

Evolution of Ambulatory Care Nursing

• Drivers of change

• Redefining health care

• Primary Care is essential care

• Telehealth Services

Practice environment

• Primary Care is the cornerstone of:

Internal Medicine

Family Practice

Pediatrics

Women’s health clinics (OB/GYN)

Telehealth services

Ambulatory Care as a Science and an Art

“Ambulatory care nursing is a

practice. Like nursing in general, a

learned profession and discipline

requiring the application of a core

body of knowledge from the

biological, physical, behavioral, and

social sciences. It is both a science

and an art.”- AAACN 2010

A Science of Practice

• Six step nursing process…..

1. Nursing assessment

2. Diagnosis

3. Goal/outcome identification

4. Planning

5. Implementation

6. Evaluation

The Many Hats of the Ambulatory Nurse

• Patient Educator

• Care Coordination

• Provider Support

• Telehealth Triage

• Mentor

• Leadership

• Staff Education

References

• Edward Wagner: The chronic care model and integrated care https://www.youtube.com/watch?v=K-z6HjRkKSc&feature=youtu.be

• GraphicStock- www.graphicstock.com

• Scope and Standards of Practice for Professional Ambulatory Care Nursing, 2010 – 8th Edition

• The Chronic Care Model –Ed Wagner http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

• You Can’t Scare Me…I’m a Nurse https://www.google.com/clipart