Daren R. Anderson, MD
Daniel St. Hilaire
Margaret Flinter, PhD, APRN
Care coordination is a core element of the Patient-Centered Medical Home and requires an effective, well educated nursing staff. A greater understanding of roles and tasks currently being carried out by nurses in primary care is needed to help practices determine how best to implement care coordination and transform into PCMHs. We conducted an observational study of primary care nursing in a Community Health Center by creating a classification schema for nursing responsibilities, directly observing and tracking nurses' work, and categorizing their activities. Ten nurses in eight different practice sites were observed for a total of 61 hours. The vast majority of nursing time was spent in vaccine and medication administration; telephone work; and charting and paper work, while only 15% of their time was spent in activity that was classified broadly as care coordination. Care coordination work appeared to be subsumed by other daily tasks, many of which could have been accomplished by other, lesser trained members of the health care team. Practices looking to implement care coordination need a detailed look at work flow, task assignments, and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education and license. Care coordination represents a distinct responsibility that requires dedicated nursing time, separate from the day to day tasks in a busy practice. To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex cases, achieve improved clinical outcomes and enhance efficiency of the health system. This article describes our study methods, data collection, and analysis, results, and discussion about reorganizing nursing roles to promote care coordination.
Citation: Anderson, D., St. Hilaire, D., Flinter, M., (May 31, 2012) "Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center" OJIN: The Online Journal of Issues in Nursing Vol. 17, No. 2, Manuscript 3.
Key words: Primary care, primary care nursing role, Patient-Centered Medical Home, care coordination, Community Health Centers, work flow
How care coordination will fit into the role currently being filled by primary care nurses remains an unanswered question. Redesigning the primary care system in America has become a national priority as the United States (US) struggles to solve issues of poor access, high cost, and suboptimal quality. The Institute of Medicine (IOM) recently highlighted the critical role that nurses will play in this redesign, emphasizing the need for nurses to practice to the full extent of their education and training (IOM, 2011). Many practices, including ours, are implementing the Patient-Centered Medical Home (PCMH), an enhanced model of primary care delivery that requires extensive practice redesign. This new model contains many elements that require an effective, well educated nursing staff. A greater understanding of the roles and tasks of nursing in this model is needed to help guide practices implementing the PCMH.
Care coordination is a core element of the PCMH model, and represents a complex task in the current, often disjointed, system of care. Care coordination is a core element of the PCMH model, and represents a complex task in the current, often disjointed, system of care. A recent study found that a typical primary care provider shares patient care with 229 other physicians and health care providers with who care must be coordinated (Pham, O'Malley, Bach, Salontz-Martinez, & Schrag, 2009). How care coordination will fit into the role currently being filled by primary care nurses remains an unanswered question. Nurses in our primary care centers already have a wide range of responsibilities including planning care with a clinical team, administering medications and vaccines, providing patient education, conducting delegated nursing visits, providing care under standing orders of an licensed independent practitioner, and providing telephone advice and triage.
Little has been written about the role of the nurse in primary care. As part of our work implementing the PCMH model in a large, multi-site Federally Qualified Health Center (FQHC) serving over 130,000 active patients, we sought to understand how the role of care coordination might fit into the role of the generalist primary care nurse by conducting a qualitative observational study of primary care nursing activity. Community Health Centers such as ours care for over 20 million individuals and are expected to expand capacity to care for 40 million patients in the coming years. The objective of the first phase of this study was to explore in depth the current workload and typical tasks being accomplished by primary care nurses in community health centers. This information, it was expected, would help in designing and implementing a staffing model capable of efficiently providing PCMH-level care, including care coordination. This article will explore the role of nursing in the PCMH, beginning with an exploration and assessment of the roles, responsibilities, and tasks of the generalist primary care nurse.
Community Health Center, Inc. (CHCI) is a multi-site Federally Qualified Health Center located in Connecticut. CHCI provides comprehensive primary care services in 12 primary care health centers across the state. Additional sites of care include school based clinics, homeless shelters, and mobile dental sites. CHCI cares for over 100,000 medically underserved patients in the state. Over 60% of CHCI patients are racial/ethnic minorities; over 90% are below 200% federal poverty level, 60% are on Medicaid or state insurance, and 22% are uninsured. Primary care at CHCI is delivered by teams called “Pods”, with a Pod comprised of two primary care providers (PCPs), two medical assistants, and a nurse, either a registered nurse or in some sites a licensed practical nurse (LPN). Increasingly, the Pod also includes a behavioral health provider. Pod members are co-located in a shared office space. PCPs include family practice, pediatric and internal medicine physicians and adult or family nurse practitioners.
...experience suggested that CHC nurses were spending most of their time on daily “routine care” activities, and were not able to focus sufficient time on care coordination. Each CHCI nurse supports the panels of two to three providers, providing both daily “routine” care and care coordination. Nurses are educated in self-management and disease-management techniques and are encouraged to see patients independently and in conjunction with a PCP visit. In addition, nurses keep a list of complex patients in their panel for proactive care coordination and review the cases periodically with their primary care provider. However, experience suggested that CHC nurses were spending most of their time on daily “routine care” activities, and were not able to focus sufficient time on care coordination. This study was conducted to identify all the tasks and activities being accomplished by nurses, quantify the time required by each one, and lay the groundwork for redesigning Pod roles and work flows.
A workgroup of CHCI nurses, consisting of front line primary care nurses and nurse leadership, created a list of all common tasks and activities performed by LPNs and RNs (Table 1). For one week, nurses on the panel were asked to record the different tasks team members engaged in throughout the workday. The items acquired from these lists were then used to categorize and organize the different tasks into common domains. The data were used to create a data collection tool for use by a trained research assistant observer to catalogue nurse activity, including the nature of the task, type of interaction (phone, computer, in person) and the time spent completing the task. Two research assistants (RAs) used the data collection tool to independently record, categorize, and time the tasks performed by CHCI nurses (LPNs and RNs) for one full work day. To ensure the ability of the data collection tool to appropriately capture daily nursing tasks and improve the accuracy with which RAs were able to use the tool, we performed a pilot test consisting of 13 nurses working at different clinics within the agency. The data collection tool was then modified based on this pilot. We obtained study approval from the CHCI’s Institutional Review Board (IRB).
CHCI’s senior nurse manager and one of the study’s RAs recruited and organized a group of ten RNs throughout the agency to participate in the study with the finalized data collection tool. Nurses from eight different CHCI medical sites were asked to participate in the study. Factors that influenced the nurse selection process for the data collection included availability and willingness to participate in the study. Each nurse involved in the data collection process was notified prior to the date of the shadowing, and was provided information explaining both the shadowing process and the purpose of the study.
Data Collection and Analysis
The data collection process for this observational study consisted of one RA observing a nurse for roughly an entire eight-hour workday and documenting the different tasks performed and amount of time spent completing each task. After obtaining informed consent, the RA began the data collecting process by classifying each task performed by the nurse into a specific subcategory from within five broad categories: team interaction (e.g., discussions with other on-site care providers); patient interaction (e.g., instances in which the nurse had direct contact with patient); outside interaction (e.g., discussing patient with non health center personnel); and computer/paperwork (e.g., documenting patient encounters, form completion); and "other." "Other consisted of tasks that were not able to be classified by the RA during observation and were reviewed and classified by consensus during the analysis. The RA asked nurses to clarify what they were doing whenever there was uncertainty. With the use of a stopwatch, the RA recorded the amount of time the nurse spent completing each task to the nearest minute.
All observation data were combined and averaged to create a composite view of the amount of time spent in each specific task and each general category. Using the framework outlined by the Agency for Healthcare Research and Quality (AHRQ) (McDonald et al., November 2010) we classified certain tasks carried out by nurses as representing care coordination. This AHRQ framework defines the elements of care coordination including creation of a care plan; managing care transitions; monitoring and following up; supporting self-management; aligning resources to meet needs; and linking to community resources.
Ten nurses participated from eight different CHCI practice locations and were observed for a total of 61 hours. Most were reviewed for a full eight hour shift. Figure 1 shows the broad categories of tasks nurses were engaged in, arranged in rank order. Nurses spend 25% of their work time completing tasks categorized as electronic charting or paper form completion. This included documenting in person encounters and telephone encounters into the electronic health record as well as completing forms and other paper work for patients.
Preparing and administering vaccines accounted for 10% of total work. In Connecticut, unlike many other states, all medication including immunizations and vaccines must be administered by a licensed professional and cannot be delegated to a medical assistant.
Eighteen percent of their time was spent conducting delegated nursing visits independently of a provider visit, and 10% was talking on the telephone with patients. To further clarify the content of these visits and phone calls, we summarized the main purpose of the visit and the content of calls (Table 2). Independent nursing visits included a wide variety of issues including anticoagulation management, tuberculin skin test administration and interpretation, operating a retinal camera for diabetes retinopathy screening, hypertension follow up, pregnancy testing and counseling, smoking cessation, and screening and administering treatment for sexually transmitted diseases.
Using the categories contained in the AHRQ framework (McDonald et al., 2010) we reviewed all observed nursing activities and identified those consistent with the broadest definition of care coordination. These activities included patient-related conversations both within the organization and with outside care providers, as well as direct patient contact (via phone or in person) that focused on disease management, self management, or coordinating care between different care providers. In all, activities classified as care coordination accounted for only 15% of the total work load for nurses that were followed in this study (Figure 2).
Analyses such as this are uncommon in the literature. However, such studies represent the type of critical systems analysis that must be carried out to help health systems transform themselves into Patient-Centered Medical Homes. Our study is one of the first to do so and to focus on the role of nurses in primary care settings (e.g., a community health center) and thus lays the groundwork for further exploration.
...well-educated nurses in a large community health center only spent 15% of their work day engaged in activities that could broadly be categorized as care coordination, a higher level nursing function. Our results show that well-educated nurses in a large community health center only spent 15% of their work day engaged in activities that could broadly be categorized as care coordination, a higher level nursing function. A substantial percent was spent on activities that could be assumed by someone with a lesser level of education and licensure.
Care coordination work appeared to be reactive and disorganized rather than scheduled or planned. Of the time that was dedicated to care management, most was spent discussing the patient with either a member of the immediate care team (team communication) or an external care provider (outside communication). Direct face to face interactions with patients to provide teaching and diseases management comprised much less time.
Overall, study results showed that these nurses, although highly educated in facilitating patient self-care management and disease management, appear to spend a majority of their time (84%) completing tasks unrelated to care coordination. While it is difficult to say what the ideal time allotment for care coordination would be, it seems unlikely that 15% of a nurse’s work day is sufficient.
The need to coordinate care for patients with multiple specialty encounters is particularly critical given the lack of integration between specialists and primary care, which leads to inefficiency, reduced quality of care, and errors. In our analysis, we focused on evidence-based care coordination activities that can be carried out in a primary care setting. These activities included managing hospital transitions, providing self-management support, disease management for patients with uncontrolled chronic illnesses, and coordinating care with specialists. Several models of transition care management have been developed and show significant reductions in hospital readmission rates (Coleman, Parry, Chalmers, & Min, 2006; Naylor, 1999; Naylor, 2004; Naylor et al., 2011).Self-management education improves glycemic control for patients with diabetes and has beneficial effects for patients with a variety of other chronic illnesses (Anderson & Christison-Lagay, 2008; Anderson, Christison-Lagay, & Procter-Gray, 2010; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Chodosh et al., 2005; Lorig et al., 1999; Lorig, Ritter, & Gonzalez, 2003). Assigning a dedicated staff member to coordinate care for complex patients also improves clinical outcomes (Addington-Hall et al., 1992; Palfrey et al., 2004; Unutzer et al., 2002). The need to coordinate care for patients with multiple specialty encounters is particularly critical given the lack of integration between specialists and primary care, which leads to inefficiency, reduced quality of care, and errors (Mehrotra, Forrest, & Lin, 2011).
Each of these activities represents core elements of care coordination as defined in consensus statements (McDonald et al., 2010; National Quality Forum [NQF], 2010). As a key part of the PCMH, these elements represent important aspects of primary care delivery that will need to be incorporated by practices seeking to implement this model. Our results suggest that in our practice, and likely others with similar design, significant redesign of staff roles, assignments, and team composition will be required to achieve improved outcomes through better care coordination.
Our results suggest that in our practice... significant redesign of staff roles, assignments, and team composition will be required... Based on these findings, we have undertaken a broad redesign of the nurse staffing model in our primary care practices. Nurses providing care coordination need specific skills and education and require dedicated time in which they are “protected” and not called upon to handle daily nursing tasks such as telephone triage, vaccinations, and medication administration.
We are in the process of defining two distinct nursing job roles in primary care, one called “Pod nursing” and the other “Care Coordination.” Pod nurses will work closely with the front line team which includes the primary care provider and the medical assistant as well as an on-site behavioral health provider. Pod nurses will attend to the daily needs of scheduled patients, including vaccinations and medication administration, and will manage much of the telephone work, messaging, and triaging that requires a nurse. Care coordination nurses will serve as team panel managers, conducting weekly panel review sessions using patient registries and data dashboards to coordinate and plan care for patients with uncontrolled chronic illness such as diabetes or hypertension. They will create plans for patients needing care management, and will share responsibility with the primary care provider for improving chronic disease outcomes and preventing hospital admissions/readmissions. Additionally, they will coordinate care for patients with positive cancer screening tests to ensure that they receive timely and appropriate follow up. They will receive all incoming reports of emergency room utilization and hospital discharge and contact these patients within 24 to 48 hours to manage their care transitions. Care coordination nurses will also assist primary care providers in managing complex patients with multiple comorbidities, and provide patient education and self management support in person and over the telephone.
Nurses providing care coordination need specific skills and education and require dedicated time in which they are “protected” and not called upon to handle daily nursing tasks... Future work is ongoing at our center to define the appropriate staffing ratios and panel sizes for both the Pod nurse and care coordination nurse. We have engaged multiple front line care teams in a collaborative quality improvement initiative using the Clinical Microsystems model (Nelson, Batalden, Godfrey, 2007) to test, refine, and implement this model.
One of the strengths of this study is the use of a neutral third party on-site observer to perform the data collection rather than relying on self-report. In addition, the broad domains in the data collecting tool were generally broken down into very specific categories and subcategories in which the full nature of the interaction or task was captured.
A limitation of this study was the potential for direct observation to alter the behavior of the nurse being “shadowed.” Thus the data collected might misrepresent the number of tasks performed by a nurse in a typical workday and time spent completing each task. The nurse might have felt rushed to complete tasks, resulting in an underestimated recorded time. Also, the nurse might have felt pressured to be more active during the data collection process, resulting in a larger number of recorded activities than in a typical work day.
This study may also be of limited use in other settings by the unique design of the FQHC and the specific staffing of Community Health Center, Inc. Some primary care practices have minimal or no nursing staff. Others that do may utilize them in different ways. However workload captured by this study represents a catalogue of critical tasks that most primary care practices provide on a daily basis. Licensing restrictions, unique to individual states (e.g., the vaccine protocol in Connecticut), may dictate many of the task assignments.
Findings from this study suggest that a substantial amount of day to day, task-level work is done by nurses at a large, multisite FQHC and that incorporating the higher level demands of care coordination will not be accomplished simply by overlaying this work on existing staff. A detailed look at work flow and assignments and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education and licensure, will be needed.
Care coordination represents a distinct contribution that requires education and dedicated nursing time, separate from the day to day tasks in a busy practice. Care coordination represents a distinct contribution that requires education and dedicated nursing time, separate from the day to day tasks in a busy practice. To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex care, achieve improved clinical outcomes, and enhance efficiency. This type of analysis represents a useful approach for any health system seeking to optimize roles and critically evaluate its work. How primary care practices incorporate care coordination will vary based on practice size and setting, but each practice needs to address this fundamental need in order to fully embrace the PCMH model. This requires changes to workflow throughout the practice along with adjustments to role definitions among members of the care team.
Daren Anderson, MD
Dr. Daren Anderson is VP/Chief Quality Officer of Community Health Center, Inc. In this role, he is responsible for implementing an agency wide quality improvement infrastructure using the most current quality improvement tools including Clinical Microsystems, Six Sigma and Toyota-Lean. Dr. Anderson also works as a clinical investigator in CHC’s Weitzman Center for Research and Innovation in Primary Care conducting independent research and working with other CHC investigators to promote research and development in primary care redesign, health disparities, and patient-centered care. Dr. Anderson obtained his undergraduate degree at Harvard College and his medical degree from the Columbia University College of Physicians and Surgeons. He completed his residency training in internal medicine at Yale-New Haven Hospital and is a board certified general internist.
Daniel St. Hilaire
Daniel St. Hilaire graduated from Wesleyan University in Middletown, Connecticut, in 2010 with a BA in economics and pre-medicine studies. During his time as an AmeriCorps member at Community Health Center, Inc. (CHCI), he served as research assistant to the Chief Medical Officer and Chief Quality Improvement Officer. He also served as the diabetic retinopathy program coordinator. In these roles, he contributed meaningfully to CHCI’s telemedicine initiatives and research surrounding CHCI’s model of patient-centered care. Daniel is now a research assistant in the Division of General Medicine at the Brigham and Women’s Hospital in Boston, Massachusetts.
Margaret Flinter, PhD, APRN
Margaret. Flinter is the Senior Vice President and Clinical Director of the Community Health Center, Inc., a statewide, federally qualified health center serving 130,000 patients across Connecticut and is also the Director of its Weitzman Center for Research and Innovation in Primary Care. In her 30+ year career as a nurse, family nurse practitioner, executive leader, and policy advocate, she has been integrally involved in the development of community-based primary care systems that improve the health of individuals, families, and communities.
Margaret earned her Bachelors Degree in Nursing from the University of Connecticut, her Master’s Degree from Yale University, and her doctoral degree from the University of Connecticut. She is a former Robert Wood Johnson Fellow, 2002-2005, co-chaired the Connecticut legislature’s Health First and Primary Care Access Authorities, and currently is the co-Director of a Robert Wood Johnson Foundation national project studying primary care teams.
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© 2012 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2012
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