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Nurse Billable Visits in Primary Care @ Unity Health Care

Overview

Unity Health Care incorporated nurse billable visits into its community health center practice in order to increase nurses’ roles in patient care and improve patient access to care, disease management and patient education.

Innovator(s)

Janine Resilard, MSN-Ed, RN

Editors

Anabel Starosta, Graduate Student Editor

Meg Krasne MPH, Director of Content

Location

Unity Health Care in Washington, District of Columbia.

Organizational Context

  • Unity Health Care is a network of 25 community health centers which are designated Federally Qualified Health Centers and Patient-Centered Medical Homes across Washington, D.C. which serve predominantly underserved populations.
    • Ten of these centers are traditional health care centers that provide Primary and Specialty Care.
    • The other centers include School-Based Health Centers at 2 public high schools and 10 homeless outreach sites.
  • An executive management team consisting of a VP of Clinical Operations, Chief Medical Officer, and Chief Executive Officer, oversee operations for all clinics.
    • Each clinic has site leadership consisting of a medical director, nurse manager and health center director
  • Implementation of nurse billable visits/number of visits each nurse initiates is variable throughout the different clinics. This is due to differential intervention uptake at sites where nurses spend more time conducting task-based activities, although ideally such sites will increase uptake.
    • Clinics wanted to reduce emergency services utilization and connect patients to more continuous care, rather than relying on walk-ins.
    • Physicians faced time-constraints and had limited open availability for patient visits, so clinics wanted to maximize nurses’ roles in managing care within the scope of their license and expertise.

Population Served

  • Unity Health Care serves over 100,000 patients, mostly from underserved and vulnerable populations and many of whom are high emergency services utilizers.
  • Most patients are covered by Washington, D.C. Managed Care Organizations (MCOs), such as Trusted, AmeriHealth, Alliance.
    • MCOs are organizations that have contracts with state Medicaid programs and accept monthly capitation payments per member.  Medicaid programs contract with MCOs with the goals of reducing Medicaid program costs and improving care utilization, while providing enrollees with Medicaid health benefits.
  • Other payor sources include Medicaid, Medicare and private insurance.

Project Leadership

  • This project was initiated by Unity Health Care’s Associate Director of Nursing Education in 2014 who worked with the IT team and Billing/Patient Financial Services Department to speak with insurance companies.

Project Components & Tools

 

  • Research & Planning
    • Unity Health Care’s Billing department spoke with insurance companies to determine the requirements to make nursing visits billable. Insurance companies were receptive to reimbursing for nursing visits, but required specific billing codes and elements included in documentation.
    • In order for a visit to be billable:
      • Provider must refer patient to see a nurse, and order this as a procedure.
      • The following must be included in the procedure order: the name of the provider ordering the visit, the date on which this was ordered, and the reason/clinical goal for this visit.
      • Standing orders are not acceptable.
  • Tools or Products Developed
    • Initially, a template was created in the EMR for nursing visits, but was found to be too restrictive.
    • Now, we have a nurse visit checklist, which functions as a formula, listing what tasks must be included in a visit and the corresponding documentation required so the note can be closed/ visit can be billable.
    • Nursing checklist includes:
      • Medication reconciliation
      • HPI
      • Review visit goals
      • At least 3 vitals
    • If vitals are abnormal or nurse has questions about visit, visit can be upgraded for patient to see a higher level provider.
  • Training
    • Training for RNs was initially led by the Associate Director of Nursing Education and a medical provider, in collaboration with the IT team.
    • Training curriculum spans many topics, including:
      • Introduction to Community Health
      • Clinical Orientation
      • Chronic Disease Management
        • Tuberculosis, diabetes, respiratory conditions, HIV, hypertension
      • Nurse Visits Procedure
      • My Health GPS
      • Transportation Services Referrals
    • This training is conducted through meetings and online modules, such as NetLearning modules.
  • Other Steps to Implementation
    • Program began in 2014, initially with nurses only billing for BP checks.
    • This has subsequently expanded to also include wound care, chronic disease management, disease-specific education, immunization, and medication management/reconciliation visits.

Tech

  • E-Clinical Works (EMR)
  • Azara
    • Azara is a healthcare system used along with an EMR for data reporting and analytics, and creates reports for population health and chronic disease management.
    • Unity Health Care uses Azara as a pre-visit planning and registry system that, linked with the EMR, can be utilized by nurses to review patients assigned to their site and determine which patients they should reach out to.

Team Members

 

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • RNs
  • LPNs

Daily Workflow

  1. Physicians, PAs or NPs refer patients to nurse and order visit as a procedure with aforementioned requirements.
  2. RNs schedule and see referred patients; RNs can also seek out patients who are high ED utilizers or have multiple chronic conditions through Azara and send note to MDs, PAs, or NPs requesting provider order for referral.
  3. LPNs can do follow up, but RNs must do initial visits and disease-specific education; RN visits account for the majority of nurse billable visits.
  4. RNs or LPNs conduct pre-visit planning and check registration details based on the provider’s note, and must write note according to nursing checklist to close visit.
  5. Nurses are expected to conduct 4 visits/day or 80 visits/month.

Budget

No additional startup cost for intervention.

Current Status

  • Intervention is currently ongoing, with variable utilization of nurse billable visits across the 9 Unity Health Care CMHs.
  • Insurance companies vary in reimbursement depending on the visit’s purpose, ranging from $40-$219 per visit.

Outcomes

  • Key Outcome
    • Increased Revenue: In 2017, Unity Health Care generated $300,000 in revenue from nurse billable visits, and had 5000 nursing visits total.
      • Key outcome currently is the number of visits nurses are overseeing, relative to the expected 4 visits/day or 80 visits/month.
      • Unity Health Care tracks Quality Improvement outcomes such as linkage to care, trimester of entry for pregnant patients, HIV rates, and depression screening rates. 
        • However, these outcomes are not specific for nurse billable visits, and currently have no program in place to specifically measure patient outcomes related to nurse-led visits.
  • Future Outcomes
    • Unity Health Care hopes to begin measuring nurse billable visits, their utilization and their efficacy in terms of patient outcomes in the future.
    • Currently, their goal is to encourage nurses to conduct visits consistently across all sites and increase utilization of nurse billable visits at clinics where uptake is low.

Benefits

 

  • 1:1 care coordination between patient and nurse, such as allowing patients to spend more time asking questions and nurses to review medications and disease processes with fewer time constraints.
  • Nurses can manage many of the problems which patients were walking in for, allowing medical providers to have more availability in schedules for appointments.

Challenges

  • Unique Challenges to the Intervention:
    • High no-show rate for visits with all providers.
    • Location: clinics do not have dedicated exam rooms for nurse visits and some nurses do not have their own offices.
      • Currently, nurses with such difficulties will meet with patients in available rooms or in very small offices that are not designed for more than one person.
  • Personnel Challenges:
    • Consistency in nurse billable visit scheduling: nurses get caught up responding to emergencies, managing patient flow, or completing task-based jobs, reducing the number of visits they schedule.
    • Intervention uptake variable based on clinic site, with some clinics incorporating nurse billable visits more avidly than others.

Relevant Quality Metrics

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