Nursing Plan

- [voiceover] good afternoon everyone. we're gonna give everyone just a minute or so more to continue logging in, and then we will get started. thanks for joining us. all right, good afternoon everyone, and thank you so much for joining us on nurse visits, a tastingflight of visit models. my name's rebekah bally.

i'm a facilitation andimprovement specialist with oregon healthcarequality corporation, which has been contractedby healthinsight oregon, to coordinate and facilitate these learning andaction network webinars. my role today will be to simply moderate. first just a brief introductionto you to the healthinsight. healthinsight is thequality innovation network, quality improvementorganization, or qin-qio,

serving nevada, newmexico, utah, and oregon. there are 14 qin-qios thatbring medicare beneficiaries, providers and communities together, in data driven initiativethat increase patient safety, make communities healthier, better coordinate post hospital care, and improve clinical quality. qin-qio work is groundedin principled aligning with the goals of the the center's for

medicare and medicaidservices, cms quality strategy. their strategy to eliminate disparities, strengthen infrastructureand data systems, enable innovation and fosterlearning organization, along with 13 other regional qin-qios, healthinsight is leadinghealthcare quality's initiative, including the million hearts initiative for the medicare programfor a five year period from 2014 to 2019 as guided by cms.

this webinar is part oflearning and action network, lan efforts of (mumbles) under the cms project on cardiac health. we are pleased to b eoffering continuing education units for nurses on this webinar today. if you would like to receive ceu credit for this activity, please note that at the end of the webinar you'll be asked to fill out a survey, and at that point

you can enter your nameand license number. a quick bit about our technology as well. throughout the presentationwe'll be checking in with you. so, just wanna make sure everyone is comfortable with the technology. on the right side of your screen is a question and answer panel. if you have questions, please feel free to enter those at any pointthroughout the presentation.

don't feel like you haveto wait 'til the end. to reduce feedback noise everyone will remain on a global mutethroughout the presentation. we can unmute you if you'dlike to speak your question. just raise your hand, this little icon next to the left of your name. lastly, we'll also be doing some polling in this webinar, which is real exciting. so keep your eye out for that,

and we'll explain as the time goes. here are our learningobjectives for the day. we'll revisit thosethroughout the presentation. but without further adoi am so happy and pleased to present our wonderfulspeaker for the day, charmian casteel. charmian has great career in nursing. she chose nursing inorder to have a meaningful long term relationship with patients,

focusing on health and well-being. her career has been filledwith fun positive experiences, especially since earning amasters degree in pediatrics. she has provided nursingcare and leadership in school based nursing,research, family planning, chs home visits, familypractice, pediatrics specialties, and nursing supervision. living by the motto ofreaching her greatest potential by helping others reach theirs,

led her to the role of primary care innovationspecialist with care oregon. being part of a team offorward thinking professionals in service to healthcareworkers and patience statewide, has opened the shutters, windows, and doors to new relationships and an even more rewarding nursing career. so you can tell she is very qualified for speaking on this topic andwe're so excited to have her.

with that, take it away charmian. - [charmian] hello. so i will be your nurseserver for your nursing flight tasting today. just one disclaimer, justto make it perfectly clear, i understand and i recognize that nurses have been taking careof patients for decades, and that nurses have had nursevisits for a very long time. this webinar is to providea high level overview

of the current lingo andunderstanding in practice of specific types ofnursing visits happening both in oregon and nationwide. so the agenda for today is, why are nursing visits important? and then we'll spend a little time talking about the differenttypes of nursing visits that are currently in practice, a description of a nursinginnovation collaborative

that we completed at care oregon with eight statewide healthcare systems, and there'll be a q and a about how you could go about developing a plan if you want to implementthese specific types of rn visits in your clinic, and then how you're gonnaactually develop that plan, and then next steps. so first, why nursing visits?

the next four slides talkabout what the projected need for primary care physicians are to provide the care that'sneeded for patients. as you can see on each one of them, here's nevada needing a 77% increase in primary care physicians, new mexico needing a 23% increase, oregon needing a 38% increase, and utah needing a,

sorry, i can't read that very well... 46, sorry about that. so the projection is ifyou don't have enough primary care physicians, then who's gonna provide the care for thoseprimary care patients? the thinking with the collaborative is, that nurses are set to provide that care. so why nursing visits as apposed to some other format or venuefor the primary care patients.

there's five reason. so we're gonna go through these. the first is healthcare costs. i don't think anyone can really argue how much healthcare costs currently, and how it's changed over the years, and how nurses are generally looked upon as people who can provide the care but at a lower cost of aprimary care physician.

provider burnout. the stats for provider burnoutare pretty significant. there was a recent literature that i read about the provider burnout, and it's somewhere along the line of 63% of family medicine physiciansreport burnout symptoms. so that's a huge issue in primary care. access. one of the main reasons for the clinics

that i've researched in prepfor the nursing collaborative, and those that attendedthe nursing collaborative, was the need for accessfor their patients. the providers had a huge panel. patients couldn't getin in a timely manner for their healthcare needs. their time to 3rd next availablewasn't looking to good. there were all sorts of access issues that can be addressed through nursing visits.

team based care. so there's also significantliterature around increased staff and patient satisfaction through team based care providers. i forget what the percentage is if a provider was to provideall the care for every patient, it's over 24 hours a day,so an impossible task. so using nurses in thatteam based care model is a great way to addressthe patient care needs

for our patient population. and last but not least,nurses have a unique skill set to provide patient care bothin the primary care setting and frankly everywhere else that we work. it think that the trainingthat's needed for rn visits, we'll talk about that a little later, needs to be addressed in academia. but even with our current skill set, we are, i'm gonna go out on a limb and say

we're the perfect rolefor providing patient care and nursing visits in primary care. so what type of nurse visitsare we gonna talk about today? so there's four types, andthe language that's used in this is not necessarilyagreed upon 100%. i think the language is very fluid, and clinics choose allsorts of different names for the nurse visittypes that they employ. we're going to use what's most commonly

understood as the nurse visits that are currently in practice. so the first on is a flip visit, an independent visit, a protocol visit, and a co-visit. a flip visit, and we'll gomore into detail on these, a flip visit is where thenurse begins the visit with a patient and flipsthe visit to the provider. a co-visit is where a providerand a nurse are seeing

the patients together. so that takes all sorts ofdifferent timelines and forms. and once again, we'll go into that later. but the language aroundthat is often called a co-visit where theprovider and the nurse is together in the room. there are independent visits, and i think nurses have been using independent nursing visitsfor a very long time.

we see patients with outthe input of a provider or an na in the room for chronic disease, for wound care, for allsorts of patient care needs. those continue, and we willtalk about those more in detail. and then the protocol visit which is, often can be the big elephant in the room when you're talking to yourleadership around nurse visits, and that is the nurse has awritten and vetted protocol to see and assess and treat a patient

independent of the provider. so the nurse uses that written protocol to help make decisionsaround patient care, and often will also includea treatment, guidelines and the ability to prescribemedication per the protocol. one thing about nurse visits is you can start a visit assay a protocolized visit, and in the practice of the visit, the nurse assesses thepatient and realizes

the patient no longer fits that protocol, and the visit has to change into another kind of nurse visit. or the nurse starts what he or she thinks will be a flip visit, andit turns into a co-visit. so unlike where provider visits, the language is pretty much the same as the provider visit and the provider is responsible for everything,

nurse visits can morphinto a different type of visit during the visit itself. so my little graphic here with the visits kind of floating into each other, i think that's a very realpiece of nurse visits, and it needs to be part of the discussion when your clinic is thinkingabout implementing them. but no matter the language you use around how you want to move forward,

often the nurse makes the determination based on patientpresentation or assessment, but the nurse visit willtake on some other form, if you will, during thecourse of the visit. time for a poll. - [rebekah] alright, so the poll is over which of these visit types, so we've just givenyou a short definition, would you like to explorefurther and in more detail

on this webinar. we'll touch on all of them, but if you want us to go specifically into more detail about one versus the other. and it looks like most of you are quick find your poll on theright side of your screen. great, we'll just giveeveryone another few seconds. few more people to chimein with their votes, and i see a couple peoplechatting in their vote

in the question and answerpane, which is perfect. all right, i'm gonna goahead and close the poll. thank you, everyone, for participating. and there are our results. - [charmian] sorry, oh here we go. i'm looking at your results. so we have 65% protocolized, and then second is new patient co-visit. okay well, no surprise there. (laughs)

i think as i, when i wasgoing through the description protocolized rn visitsare certainly the most innovative and forwardthinking of the four visits that we're gonna talk about today. so, thank you for polling. that was awesome. so briefly, let me, and you will get a copy of these slides. so each visit has thesefeature tables on them

describing what thepotential for the rn role will be during the visit, the provider role during the visit, and how positive ornegative that type of visit will impact the clinic and the patient. so, i'll let you review those, and we'll dive deeper intothe protocolized ones. but, once again, thesetables are guidelines. i think within your clinic itself

and within the state that you practice in, scope of practicecertainly impact what role the rn has in each of these visit types. so that always needs to be addressed when you're implementing the rn visits. so here's the flip visits. what the nurse would do. and i had a question mark at scribe. i was actually visiting a clinic

where the nurse scribedduring the provider portion of the flip visit, which is an interesting role for nurses, and it was interesting to see. doesn't necessarily have to be that way, but that certainly is anoption for a flip visit, for the nurse to stay in the room, similar to a co-visitbut the nurse simply acts as a scribe during theprovider piece of the visit.

there is a new patientestablishing care co-visit. so the new patient piece of it, i'll have to mention the billing piece, so according to cms, nursescannot bill new patients. so this would be a nonbillable visit for a nurse, if it was a new patient,but that still doesn't mean that the nurse can't be apart of a new patient visit for a provider. so, once again, thelingo can be challenging,

but the nurse would seethe patient initially, during the visit, and thenwhen the provider came in the nurse would still be in there and be an active part of the visit, but it would be billed under the provider. so this would be thepotential for the nurse role, once again the provider role, how it would impact theclinic and the patient. i'm gonna skip to the rn visit itself.

so these are visits that we've done for a really long time in primary care. whether it's in the triage form, or a patient walks inand we see the patient and make a determination using our nursing and critical thinking skills, or whether it's scheduled for wound care or chronic disease management. this is a visit that's beenaround for a really long time.

these are the roles, once again, and how it impacts theclinic and the patient. all right, let's get tothese protocolized visits. so a protocolized nurse visit, wow, can be really challenging, and also really awesome. it takes a lot of work. and it takes the inputfrom a lot of leadership, and provider and nurse communication

to write a protocol,to train to a protocol, and to implement a protocol nurse visit. there are lots of examples out there that are available as a template for protocolized nurse visits. and there are requirements, likely from your board of nursing, for what the protocol has to entail. and certainly if you're going to

bill a protocolized nurse visit, there are requirements as well. a protocolized nurse visit, once again, is not, like all thevisits, is not the same for every clinic that'sgoing to employ it. some of the clinics thatwe have worked with, and that i researched, do nothave any treatment options in a protocolized nurse visitthat require a prescription. so there are nurse treatment options,

but they do not make theprescribing of medication part of a protocolized visit. others do, and it isembedded in their protocol. it's a part of the conversationthat needs to happen within the clinic as to whether you decide to take that step in the protocol for your protocolized nurse visit. so there's also adiscussion around whether a protocolized nursevisit is symptom based

or diagnoses based, basedon scope of practice that says a nurse cannotgive a medical diagnoses. so figuring that out andcommunicating with your leadership needs to be another part if you wanna move to a protocolized visit. is it gonna be symptombased in the patient that walks in with ear pain, or is it gonna be written the language where you do a medical diagnoses

around whatever the diagnoses is. i can tell you that most of the clinics, to get around thatmedical diagnoses piece, are doing symptom basedprotocolized nurse visits. so the protocol includeseverything that is required for the nurseto follow the protocol, but also required tobill the visit itself. so that's why under the rn role it says all visit components per the protocol.

some clinics would havea na do the vitals, but we certainly havethe skillset to do that. we have the skillset to asses the patient, to take the history, to provide all of the point of care testing, to follow the protocolif the patient meets all of the assessment and history for whatever that symptom may hit, and to follow treatmentguidelines from a provider,

and complete the visit,and send the prescription, if that's what your scope ofpractice in your state allows. so if it's a completely independent protocolized nurse visit, you're provider has norole in it whatsoever, other than the medical director has already signed the protocol for the nurse to practice underneath of him. the provider does not haveto step into the room,

the nurse follows the protocol, and makes that determination whether the patient meets the protocol or not, and then as i mentioned earlier, it could flip into adifferent kind of visit if the nurse assesses the patient and realizes they don'tfollow the protocol. how does that impact your clinic? well it can be challengingwhen your schedulers

try to figure out which patient falls under your protocolizednurse visit protocol. so having a matrix, ortraining, or however you want to move forward with your scheduler to make it easier on them, who goes on the nurseprotocolized schedule and who doesn't, can be challenging. it certainly a positive for your provider because the goals is to not have

them have to step into the room, and therefore they have patients that can see a nurse and they canfill up their schedule with other visit types. it can reduce your timeto 3rd next available if you use protocol for low-acuity visits like sore throat and ear pain, and whatever the symptombase is that you decide, those patients can see the nurse.

and once again the provider can reduce their timethe 3rd next available. reimbursement can be challenging, and we'll talk about what the incident-to is and what are the requirements for that. but you can certainly billprotocolized nurse visits if you meet those requirements. and then as a nurse, the scope and yoursatisfaction with your job,

when you're able to seea patient independently, when you have that trainingit allows you to see that patient when you havethat added patient interaction, when your patients seemmore satisfied it just, i don't think you canactually put it into words what that means as a nurseto be able to provide that. and then for the patient,they can certainly get in in a more timely, hopefully,in a more timely way. so they're getting the carethey need in the time they need,

because they're seeing a nurse rather than waiting for a provider. this is from me, but ithink that every patient interaction is benefitedby rn intervention. so your patients being able to see a nurse to me just makes sense. the negatives, if you wanna call that, for the providers, there's been providers that will continue tofeel like their missing

out on their interactionwith their patients, especially for low-acuity,that they miss that, that they're not getting tosee their patients as much. there's that sense that they're handing over their care to someone else. and i think it's important toaddress that in the beginning with your provider groupwhen your talking about implementing rn visits,to have that discussion, and to talk about howtheir gonna feel about that

if you wanna start with certain protocol so that they have somecontrol over who's seeing their patients and for what. i think that needs to definitely be a part of the communication, bothinitially and ongoing. and lastly, establish patient only. so, once again, there are requirements for a nurse to see a patientunder a protocolized visit, and certainly to bill for it.

nurses cannot bill for new patients, and part of the incident-to is that the pcp has requested, if you will, the protocolized visit, so the current state of healthcare and nursing visit is, a protocolized visit needs to be with an established patient only. i have a question here. "can lpns do protocolized visits?"

so that is scope of practice, and that is an awesome question. we addressed that in the collaborative that we did here, whether or not it's within an lpns scope of practice to see patients independently. i would refer you to your board of nursing and the scope for lpns in your state. it is not the same, just asthe nursing scope of practice

is not the same in every state. that includes lpns. moving on. so that's a protocolized nurse visit. deeper dive. how we doing on time? - [rebekah] good. - [charmian] okay. so reimbursement.

this is the other elephant in the room, is how you're gonna billfor your nurse visits. so you train your nursesto follow a protocol or to have, if they've been a triage nurse for a long time, and theyhaven't had direct patient care, that added updated training on health history and assessment, and now you want reimbursement for that, which makes absolutesense, and should always

be a part of the conversationwhen your implementing either. there are a lot of rules around it, and it can be challenging, and there are some things that you can do to ensure or to feel betterabout seeking reimbursement. but i have to say thisis a really new thing, reimbursing for a nursing visit. and it's kind of, it's an unknown. so there can be some anxiety around that,

but i think like everythingelse that we do in healthcare, if you understand what it is that you need to do and you make every effortto follow through with it, that you should feel confident that your doing the right thing, and try to seek outreimbursement for nurse visits. so this screen is courtesy of a webinar that your gonna see in the reference list, but is also courtesy of cms.

so these are the requirementsfor reimbursement for a 99211 for a nurse visit. so once again the patientmust be established. so a nurse cannot billfor a patient care visit if they are a new patient. once again, it doesn't meanthey can't see that new patient. we can provide care to everyonethat walks in the door, including those new patients. and if that works for the clinic,

then you should certainly implement that, but you couldn't bill for that new patientvisit under the nurse. there needs to be an evaluationand management service. the service has to be separate from another visit on the same day. there has to be a plan ofcare or provider consult. and this is the part in thetable that we talked about where the provider hasto provide guidelines

that the patient can see the nurse under that protocolized visit. so if a protocol isn'tin the patients chart or emr or isn't reverenced by the provider in the chart that they want that patient to see the nurse under thiscondition with this protocol, however you wanna language it,then you can't bill for it. it doesn't mean the nursecan't see that patient under a nurse visit, butyou couldn't bill for it

without either the providerstepping in the room or the nurse consulting with the provider and documenting that, or thatplan of care in the chart. those are required for youto bill the nurse visits. and then the physician,or the billable provider, or nurse practitioner, or pa, once again, whatever your statehealthcare currently is, must be immediately available to provide assistance in direction.

so during a collaborative this came up. what does immediately available mean? does it mean onsite? does it mean one floor above? does it mean across thestreet at the coffee house, on a break, what cold that be? well i would just supportyou if the provider isn't there in the clinic. if they aren't immediately available

if the nurse was to have somethinghappen with that patient, then that is not immediately available. if during assessment, thatnurse needs a provider, and it doesn't have to be the provider that wrote the plan of care. it doesn't have to be the pcp, but if there isn't aprovider that's available during that visit, then you'renot meeting the requirements for reimbursement for that visit.

phew! okay. so this collaborativethat i keep talking about, these are the dates that wecompleted the collaborative. this is the first collaborativefor nursing innovation that i'm aware of in care oregon. we provided clinicsacross the state of oregon to come very single month for four hours to talk about nursing visitsand how to implement them, and the costs through it.

these are the dates. these are the things that we talked about. these are the things thatwe educated each other on, that we shared knowledge,and that we learned from, in order to implement nurse visits. the information for this came from a number of different sources, and they're some in your reference list that i really support you in reading.

but there were threeclinics around the nation that i researched and went tovisit in preparation for this. they are a clinic in california,a clinic in colorado, and then one here in oregon. and the format or theagenda that you see here was based on my researchin visiting those clinics. communication is the first one because it is the most important thing. i can't stress enough that

this is a huge culture shift for a clinic to take to start havingtheir nurses see patients independently and bill for them, and to have protocols for nurses so communicating from the start, in the middle, then end, and every other time you can think about is gonna make or breakimplementing nurse visits, and is impossible to sustainif you don't continue

the conversation with your leadership, your providers group, and your nurses. so, and the other piecesthere are important as well, and you have your communications, and figure out how you're gonna implement, i would use that as a reference. have we covered this? how are we gonna addressdocumentation billing? what is the visit gonna look like?

all of those pieces that you see there. the next three or fourscreens are the actual report outs from the clinics that attended the nursing collaborative. so you will see that thereare no names attached to them. the reason that i wannashare this with you is so that you can look atthe progress that they made. whether you consider how long it took or who was involved with it, or how fast.

whatever you can glean from these, i think it's really importantfor you to review this to see what the clinicsactually reported out, how this process happened for them. and i will leave you toreview these at your leisure, so that you understand the colors. so green means that theyactually wrote a protocol during the collaborative. yellow highlight is they trained.

whether trained with a provider, whether they providedspecific nurse training, however they chose to train their nurses in preparation forthis, that's the yellow. the purple is they implemented visits. so they had protocol, theycompleted their training, whatever process they went through, they were able to,during the collaborative, implement some form of an rn visit.

and then there's another color. so the blue is they founda champion in the clinic, which could be a clinician,could be a nurse, someone that championed thisprocess for their clinic. and i think that's very important as well. there needs to be someone whosays there is value in this, and i wanna see it happen, and i'm gonna guaranteethat we move along, in the way that whateverworks for the clinic.

so that's what the blue us. so you, once again, will see the process the clinics went through. i wanna call out a couple. so here, number 7, this clinic had a really challenging time, in that halfway through the collaborative, their medical directorreceived a terminal diagnoses. and i wanna call that out because

i think that it can be more challenging when you have a change in your leadership. whether it's someonethat leaves the clinic, or a change in roles, or for instance, this clinic with the terminal diagnoses, it's very easy to havethis huge culture shift be derailed by that. so planning for that and, once again, communicating about that so that you

don't lose the momentum, that if you need to reshape or reframe how you wanna move forward, needs to be a part of that communication and understanding of implementation. the clinic number eight here, if you can see, they haveevery color that i highlighted. they have so much peopleon board with this, people had so much fun with it,

and every time we met theyhad so much to talk about, their movement was really, it was huge and it wassatisfying for them, and they took the time that they needed. i think they're just agreat example of a clinic that started where they neededto with the communication. if you look at first session, they have that provider champion, they found that champion,they started training,

they started writing their protocol, they really put a lot ofthought and effort into this to get to where, you see in session four, they had multiple protocols ready to go for their nurse visits. questions. - [rebekah] okay, we havetime for a couple of questions before we move on to the next section, which will be helping you develop a plan

about how you are going to potentially take this back to your practices. so now's the time to askany clarifying questions. if you want us to go back withsomething, now's the time. so one question we got, charmian, was, "for rns seeing patients forchronic disease management, "do they typically work fromprotocol in your experience?" - [charmian] i think itdepends on what you want, what the clinic wants thechronic disease management

to look like. i think if part of the chronicdisease management visit is a titration of medications, whether it's for someone with a diagnoses of diabetes or hypertension. if that's gonna be a piece of the chronic disease management. if the nurse followingassessment of the patient, makes the determination that there needs

to be some kind of medication change, that a protocol for thattitration is important. - [rebekah] okay. thank you. there were also a couple ofquestions about implementation. i know that you were talking about the collaborative a little bit. but a few people wanted to know what were some of the challenges in that. that would be ifleadership can't be a part

of the process for whatever reason. but what other challengesare you finding in practices. - [charmian] mm-hm, soboth with the clinics that attended the collaborative, and also the three thati visited in preparation for the collaborative,the biggest challenge, and the reason that i talkabout it all the time, is the communication. so for all of the clinics, ithink the biggest challenge

for the communicationwasn't actually initially finding someone in theirleadership or provider group to jump on board and buyin and be a part of it. it was the communicationthat's required to sustain it. especially between theproviders and the nurses. because you have turnover. you have providers thattake on different roles. you have nurses thatinevitably get moved around, and their duties either getadded to or in some way change,

and having that opencontinuous communication between the provider and the nurse. it actually is based on mycommunications with the clinics. it is the biggest challenge, is having that all the timenot and not having it stop. making sure that you have dedicated time whether it is before thevisits, after the visits, dedicated time in meetingsfor providers and nurses. for part of this to talk about

what's happening in the visits, how they're feeling about it, how they're communicating with each other, how the documentation is going, sustaining that so that you can (mumbles) - [rebekah] so that's mostlyjust informal communication, or is that if any written communication about that goes out to the clinic? - [charmian] well one of theclinics that i researched,

that i imagine a numberof you have heard about, is clinica in colorado. while i was there they talked about all of the different ways that they tried to sustain communication, healthy communication betweentheir providers and nurses. and one of the mostrecent efforts they made was a program called sbi,situation behavior impact. and they were piloting that to see if that

could help improve somechallenging conversations that happen between providers and nurses in the course of rn visits. so i think, unless you alreadyhave a trust relationship between your providers and nurses based on successful telephone triage or long standing workingrelationship with each other where the provider trusts that nurse, having whatever the form is,

having some kind of formal plan for communication isimportant to start with. maybe having them traintogether on nurse visits, however you wanna implementit in your clinic, unless your like a rockstar and already have staff that communicates fabulously, picking some formal or more structured way to start communicating is a good idea. - [rebekah] okay, great. thank you.

- [charmian] yeah. - [rebeka] somebody else askedabout feedback from patients when your working withclients in the collaborative, were any of them able tohighlight specific stories or feedback on patients on how this works? - [charmian] that's an awesome question, and i'm so glad somebody asked it. so two of the clinicsthat i visited in fact for this collaborative,

the data around things like reimbursement, and staff and patient satisfaction, didn't all flow in the same direction. so the reimbursement piece,they actually struggled with, weren't necessarily able tomeet their goals around it, but they chose to continuethe process of implementing and sustaining nurse visits based on their patientsatisfaction scores alone. they had such an increasein patient satisfaction

with the nurse visits, that that was their sustainingdrive and motivation for continuing this journey. yeah. that's pretty cool. - [rebekah] pretty cool. awesome. somebody asked about areference for the sbi. is there a specific reference for that? - [charmian] it is an established program.

i think you can actually even google sbi or situation behavior impact, and you will find information on it. if not, i think my email ishere in the slide somewhere, you can email me, and iwill send you what i have on the sbi program. - [rebekah] perfect, okay. and then last set of questions. we had a question comein, and then there were

some questions that folksposed during registration about getting more support for doing their visits in the clinic. maybe we'll talk about this a little bit in developing our plan for taking it back. but, somebody seeing this webinar, and they think it's reallygreat, they're on board, how do they then bring that back and get support fromother care team members?

- [charmian] well i think figuring out or having that discussionand communication around why. why does this clinic, whydoes our patient population need or would benefit from nurse visits, is a really important data point. and it's necessarily thesame across the board. there are some clinics thatcame to the collaborative that chose to do thisbecause their nurses asked for an increased practice, and innovation

around the care that they were doing. whether that's, i wanna getoff the phone for a while while i do a triage, or whether their rolewas more administrative and they wanted to goback to patient care, or the data around thingslike 3rd next available and whatever it may be. i think understandingwhere your clinic is at and finding that data, andstarting the conversation,

is gonna garner support thatyou need to help move this. - [rebekah] awesome, okay,so maybe we can continue talking about that a littlebit in the next few slides about bringing this backto everyone's organization. - [charmian] yeah, eventhough this is sort of a newer thing in primary care nursing, i think there's alsosignificant data out there, for instance thoseclinics that i researched, and there's an articlein the reference list

that kind of talks about, and if you need to bringback the data around why this is pretty cooland important innovation. - [rebekah] awesome, okay. oh, one last question that just came in, and then we'll move on is, "have you documented anybarriers to rn visits or patients wanting to see aphysician instead of a nurse, and if so where those challengesaddressed by other clinics?

- [charmian] yes. so i think that there'salways gonna be a patient that, especiallyinitially, because they're so used to it, patients are as used to seeing their provider asthe providers are used to seeing the patients, and nurses aren't used toseeing patients independently, that's very true. there is an absolute patienteducation piece around this.

i told a clinic the other day, when we were talking about it. i think a huge part ofthe patient education is the providers, when theyhave a patient in the room saying, "if you experience this again, "we have nursing visits available to you. "i work with this nurse."and kind of talking about the nurse and how these visits are available to patients goes a long way

toward patient understanding of and comfort level with rn visits. but yes, all of the clinics had patients who said, "i'm not comfortable this. "i wanna see my provider." some of them through thecourse of nurse visits, and actually having aprovider even step in the room for those instances, and once again, having a provider say,"this is a nurse i trust.

"we work together. i'm always available "during this nurse visit," whatever the language is. move some patients to agreater comfort level. there's always a patient that says, "i don't wanna see a nurse." sure. and i think that needs to be okay. i mean we're here to dopatient centered care.

and even though this isan option for innovation to change access and cost,and all of those things i talked about initially,the door needs to be open for patients to say, "you know what, "i just want to see my provider." - [rebekah] great. good reminder. it's about the patient. - [charmian] yep. - [rebekah] (laughs) awesome, okay.

thanks charmian. we had a couple more slides here. so the plan. so how are you gonna do this? well if i haven't said thisenough, i'll say it again. it has to be communicated. it has to be communicated fromthe nurse to the provider, the provider to the nurse, the leadership to all of the staff,

the schedulers, and to the patients. the communication needsto happen continuously, and change it up however you need to. provide it in whatever format you need to. it needs to be an ongoing partof implementing rn visits. i think it's important toget the data that you need to change minds, to move theculture within your clinic, to get the data once youimplement nurse visits. what kind of things are youchanging for the patients?

what is the 3rd next available? how are patient outcomes beingchanged by nursing visits? what is the patient satisfaction? and then using that data tocontinue to innovate further. you know whatever successesor challenges you have, what does the data show? and learn from that data. i think training the nurse,who's gonna do the training? i mean, we've been trained.

there are nurses out there that have gone to just as muchschooling as me, if not more. but if they're not used to having direct patient care with patients, if they're role has been one of administration or telephone triage, and they're not up to date, or they haven't practicedor implemented nurse visits, and so that whole pieceof patient history,

and putting a stethoscope on the patient for the first time in ten years, around the assessing ofthe patient, all of that, i think it's important to talk to your nursing staff about that, where they feel like their barriers are. even if it's just usingan ehr in a different way, because documenting anindependent nurse visit is very different fromdocumenting other things

in patient care. having the training so that the nurses feel comfortable with that. and if the provider can bea part of that training, which helps build that trust relationship, you are long ways ahead. if you can make thathappen, kudos and yay. and the last thing,i'm gonna say it again, i just can't telly you enough,

communicate, communicate, communicate. another poll! - [rebekah] another poll. our last one for the day. how are you gonna take this information back to your practice or team. it's really for us to really kind of know, did we give you enough? what else do you need?

so i'm gonna launch this here and give everyone about aminute or so to respond. we just wanna know was this great for you? you're ready to go aheadand start implementing. do you need more information? do you need support from someone? all right, i think that's everyone that's gonna get their vote in here. i'm gonna close it andshare it with everyone

so you can see it. - [charmian] okay, let'ssee where we're at. so we have 47%, theycan work on implementing some of the features, 22 not quite sure, 46 just want additional information. i love that. yay. - [rebekah] super. - [charmian] well, terrific. for those of you that wantmore information, yay.

that means that you're thinking about it, that you found something useful in this. for those of you that think you can take something back, even better. there were a couple ofquestions that came through. one was on cct codes. so the billing is another one of those monster challenges in this. there's no standard that i know about

around how to insurethat, despite everything that you do, that you'regonna get reimbursed. if you have a certified coder and biller that you can work with, thatthe nurses can work with on what documentationis required to ensure that the codes that yourusing get reimbursed, i would support you in that. the clinics that i've worked with and that i visited, thereis most often used a 99211

for an nurse visit. there was another questionaround protocolized templates or what a protocol looks like. there's actually a lotavailable just by googling it. but if you want some specific ones that i shared with thenursing collaborative, my email in on there. please send me an email. i'm happy to share.

all of the clinics that i visited freely shared their protocol with me, and were fine with me sharing because they wanted to move this implementation and this process forward forprimary care nursing as well. so here's some other references for you. care oregon, actually isgoing to be presenting at the oregon center fornursing fall conference for those of you that are in oregon.

we're gonna do a presentationon team based care in primary care nursing. there is my email for the collaborative. if you're in oregon, onceagain, there's a potential for collaborative #2 forclinics that didn't attend #1. please send me an email,and i will forward that on. the articles you see arearticles that i actually wrote in prep for this and that i had the clinics that attendedcollaborative read as well.

they're really valuableto start the conversation to have better understanding of what's happening nationallywith nursing visits. and then, as i mentioned,in the reimbursement side there's a webinar on bestpractices for documenting and billing that was provided by a coder from the multnomahcounty health department. that is a link for that as well. it's a great reference,it was a great webinar.

- [rebekah] and theinformation on that webinar was not represent their respective organizations who presented it, but oregon primary careassociation hosted it, and then we'll also includethat on our website after this. for those of you, i justwanna plug in real quick, for those of you not in oregon, i think all of your stateneeds to your healthinsight are on the call, and if they can just

type in their email there, there are resources for you as well. so if you are not in oregonand part of healthinsight, or working on the various tasks, feel free to reach out to them and say, "hey, we'd like some help with this, "with implementing this." a question i always get, and i forgot to say something about, is the recording

and the slides, yes,will be made available. following this, we'll be posting it to your healthinsight website, and each of you shouldget a link to that website within the next day orso directly from goto. and with that i will give you just a few minutes just shortly after this to please fill out thepost webinar evaluation. if you are requesting ceus, youmust fill out the evaluation

because that's the only way we can get all of your information, including your license number and some of the questions we needed to ask about how well we did today. and i just wanna saythank you so much everyone for being on the call. thank you so much charmianfor sharing your expertise and walking us through this collaborative.

it's really amazing,and i hope that everyone got a lot out of it. i know i did. - [charmian] hey, your welcome. my pleasure. - [rebekah] and the next webinar will be thursday, september 22ndon shared decision-making. so, stay tuned for thatfor a link to register. otherwise, i will give you therest of your afternoon back.

thanks so much, everyone. take care. bye.