Overview

A multi-site community health center implemented a care model expanding nurses’ roles in intake, documentation, and care plan communication, working alongside providers in “co-visits.”

Organization Name

Clinica Family Health

Organization Type
  • Community health center
National/Policy Context

  • The development of this program was influenced by Colorado’s ACO initiative and with the hope of Clinica becoming involved in a primary care capitation program sometime in the future.

Local/Organizational Context

  • In 2012, leaders of Clinica Family Health were looking for new ways to retain physicians, nurse practitioners, and physician assistants who were leaving for higher paying, low stress positions at other institutions.
  • Leadership sought to find new ways to balance increased patient load with work/life balance for care team members in an effort to retain these employees.

Patient Population Served and Payor Information

  • Clinica Family Health is a community health center serving communities near Denver, Colorado. Clinica currently has six community-based medical clinics and two dental clinics serving 55,000 patients annually. Around 2015, Clinica Family Health had five sites and served about 45,000 patients annually.
  • 98% of Clinica’s patients live at or below 200% of the federal poverty level.

Leadership

  • Each clinical site has a local Clinical Medical Director (MD, DO, NP, or PA), Clinical Operations Leader (COD), and Assistant Nursing Director (RN) (AND).
  • During the pilot, CODs and ANDs at each site worked together to oversee the nursing team at each site and partner with other sites locally to manage the program. Today, solely the ANDs fill this role.

Research + Planning

  • Around 2013-2014, Clinica’s care team model consisted of 14 “pods,” each consisting of physicians, nurse practitioners, physician assistants, nurses, medical assistants, a case manager, and a behavioral health provider.
  • Project leaders decided to evaluate their “pod” model. As part of their analysis, they completed time studies on 34 patient visits, examined the role of each pod member, and interviewed Clinica leaders and employees in high-performing practices.
  • This evaluation process showed that team members were not being adequately utilized.
    • Of 34 observed patient visits, only one patient saw a nurse. Nurses in the practice were mostly involved in phone triage, not direct patient care.
    • Because there was a lack of appointment slots, nurses often spent a lot of time over the phone redirecting patients to alternate care sites (e.g. urgent care).
  • In response, the Clinica’s community health center (CHC) piloted a RN “flip visit” or co-visit model within two of their pods. This intervention included:
    • New staff:
      • Increasing nursing full-time equivalents from 1.0 to 3.0 for each pod
        • Two nurses worked with physicians to address same-day acute complaints, with each nurse having up to eight co-visits daily.
        • One nurse was involved in standard nursing care (e.g. complex care management, patient education, wound care).
      • The creation of a triage-only nurse position, which was a position outside of the “pod”
      • The addition of a medical assistant to each pod to help with medication refills and reconciliation, vaccine administration, and other tasks
    • New scheduling:
      • A separate nursing schedule was created for the co-visits, managed by the triage nurse and Clinica’s centralized communication center.
        • The nursing schedule paralleled the provider schedule and was such that one to two co-visits replaced two standard provider visits.
      • Note: Nurses were not paired with any particular provider for co-visits, and there was no provider double-booking under this scheduling scheme.
    • Adjustments in billing, tech, compliance:
      • Work from the billing/coding team, IT team (for electronic health record (EHR) changes), and the center’s compliance office to set up the intervention

Training

  • Nurses were trained by other nurses, NPs, and physicians to document co-visits. Nurses were also trained on how to present patients to the provider after seeing them.
  • Providers were trained on how to support nurses in achieving proper documentation.

Tech Involved
  • Electronic medical record
Team Members Involved
  • NPs
  • PAs
  • Physicians
  • RNs
Workflow Steps

  • Patients are scheduled for a co-visit with a nurse, managed by the triage nurse or the central communications center.
    • The patient arrives at the visit, which takes about 20-30 minutes total (about 10 minutes for MD/NP providers).
    • The patient is initially seen by the nurse, who records the history of present illness and past medical, family, and social histories. The nurse also collects vital signs, pends relevant orders, and creates a nurse note.
  • The provider then joins the nurse in the room, at which time the nurse verbally relays the history to the provider in front of the patient. The provider clarifies details as needed.
  • The nurse then serves as a scribe, documenting the provider’s physical exam, assessment, and plan in the EHR.
  • The provider leaves the room to visit the next patient, while the nurse stays with the current patient to provide information about the care plan and relevant patient education.
  • The provider reviews and authenticates visit documentation and submits the visit for billing.

Budget Details

  • Adding two nursing positions per pod

Where We Are

  • The pilot was completed in 2015, and the intervention is ongoing.
  • The program has expanded to be program-wide recently, with the goal of 1 co-visit per pod per day across the organization. the number of co-visits has been growing over the last month since the expansion.

Outcomes

  • Patient volume: at one of the pilot sites, daily visit capacity increased by 17%. The second site eliminated double-booked visits and capacity grew by 12%.
  • Team Satisfaction: care team members at the pilot sites reported improved satisfaction and work/life balance. Some providers reported a new change of having charting completed before leaving work.
  • Patient Satisfaction: patient satisfaction for nurse co-visits averaged 9.5 out of 10, which was higher than the baseline for provider visits.
  • Cost Effectiveness: preliminary business case analysis shows that a full year of co-visit based care across all care teams, at an average of 2 additional visits per day per medical provider, covers the cost of all additional nursing and medical assistant staff and results in a positive revenue.

Benefits

  • This model of care improves access for patients by allowing for an increased number of provider visits daily. These visits also filled gaps in providers’ schedules from no-show patients.
  • It also provides nurses with more direct patient care and greater fulfillment.

Unique Challenges

  • During the pilot stage of the project, staff members were pulled from other care teams to accommodate co-visits, which meant existing teams were short-staffed.

Sources

Innovators
  • Karen Funk, MD, MPP
  • Malia Davis MSN, RN, ANP-C, NP
Editors
  • Jacqueline You, BA
Location

Denver, CO

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