To achieve the National Quality Strategy aims of better care, healthy communities, and affordable care, our health care system is undergoing a major transformation from volume-driven to value-driven care. An essential component of this transformation is reinventing primary care. Combining population health management and virtual tools for virtual population health management led by registered nurses can be a powerful strategy to strengthen primary care teams and system capacity.
Imagine you had a team of trusted health care providers who think about and monitor your health all year round. They connect with you via phone, text, or email in between in-person visits at your convenience to remind you about important preventative screenings or vaccines. They coach you through shared decision-making in reaching health goals that are important to you, including physical, mental, and oral health. They coordinate your care and medications. If you end up in a hospital, they help you transition safely back home. And, because they know your health outcomes depend on social determinants of health such as housing and employment, they help you navigate community resources to support your social needs.
It is called population health management (PHM)—a proactive approach to health care that uses data to identify and monitor populations of patients to prevent and manage chronic disease. Within the PHM paradigm, a cohort or a panel of patients is monitored on a number of vital health metrics such as blood pressure or blood glucose in real-time to systematically diagnose population level care-gaps (e.g., 40% of 1,500 patients being monitored who have diabetes have not had their yearly foot exam). PHM also provides population-level (e.g., electronic reminders that flag each patient with a missed foot exam) and individual outreach interventions (e.g., patient education) to close the care gaps. The distinguishing feature of PHM is the care team’s concern with the health of the entire population of patients, not just those who show up for a visit to request care.
Shifting time and resources from in-person visits with primary care providers to more team care and non-visit-based care using virtual tools is necessary in light of persisting shortages of primary care physicians, nurse practitioners, and physician assistants. Registered nurses are perfectly positioned to ameliorate the primary care workforce shortage if they are allowed to practice at the top of their license and in enhanced roles. RNs managing their own patient cohorts as part of a team using virtual tools to provide care independently of primary care providers is one such enhanced role which can increase primary care capacity and value. RN value-added to the team includes use of clinical judgment to lead complex care management, manage medications, coordinate care and care transitions, and supervise unlicensed providers on the team.
New Care Paradigms Require Nursing Education Reform
Presently, most nursing students have little exposure to panel management and primary care content and clinical experiences in their undergraduate education. Preparing future RNs to virtually manage population panels in primary care will require drastic reform in nursing education. In the reformed education system, nurses will need to develop competence in panel management, “webside” manner, virtual presence, and other virtualist practice specialty skills.
IMPPACT Project – A Virtual Curriculum for Virtual Population Panel Management
The Integrating Management of Patient Panels Across the Curriculum with Technology (IMPPACT) project aims to develop panel management (PM) competencies in pre-licensure nursing students with technology-mediated education. As a Macy Faculty Scholar, I am working to tailor existing evidence-based resources and virtual patient panels to develop four online, self-directed, interactive learning modules for the IMPPACT work. We will integrate these into existing nursing courses and include a debriefing tool which faculty and students can use in clinical practice to reinforce the learning.
We will use publicly-available virtual practice panels to simulate a population management experience. One such virtual practice we plan to tap into is Mott Community Practice, which has 6,300 unique patients, 6 providers, and over 7,600 visits. This web-based practice, developed at New York University School of Medicine, provides information on practice level quality metrics and provider-specific patient panel metrics, such as percentage of patients who have high blood pressure. We will ask nursing students to assess care gaps at Mott Virtual Community Practice and then select appropriate standardized care guidelines to close the identified care gaps.
Self-directed learning of abstract knowledge through interactive modules will be integrated with clinical experiences through the debriefing tool. We are also planning clinical experiences in the outpatient care coordination department where care is provided by RNs using telehealth for groups of complex care patients with our clinical partner, NYU Langone Health.
Care is complex and fragmented. Patients are lost in transitions. The IMPPACT experience aims to prepare RN students to turn these challenges into opportunities for improving our nation’s health.
References
1.Agency for Healthcare Research and Quality. (2018). National Quality Strategy. Retrieved from https://www.ahrq.gov/workingforquality/index.html
2.Bodenheimer, T., & Mason, D. (2017). Registered nurses: Partners in transforming primary care. Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation. Retrieved from http://macyfoundation.org/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf
3.Care Continuum Alliance. (2012). Implementation and evaluation: A population health guide for primary care models. Retrieved from http://www.populationhealthalliance.org/publications/population-health-guide-for-primary-care-models.html
4. Reynolds, A., Rubens, J., King, R., & Machado, P. (2016). Technology and engagement: How digital tools are reshaping population health. Retrieved from http://www.populationhealthalliance.org/publications/technology-and-engagement-how-digital-tools-are-reshaping-population-health.html
5.Knox, L., & Brach, C. (2015). Primary care practice facilitation curriculum (Module 31). AHRQ Publication No. 15-0060-EF, Rockville, MD: AHRQ. Retrieved from https://pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-31-facilitating-panel-management.pdf
6.Wagner et al. (2017). Effective team-based primary care: Observations from innovative practices. BMC Family Practice, 18(13). Retrieved from https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-017-0590-8
7.Tuckson, R. V., Edmunds, M., & Hodginks, M. L. (2017). Telehealth. The New England Journal of Medicine, 377(16), 1585- 92.
8.Nochomovitz, M., & Sharma, R. (2018). Is it time for new medical specialty? The medical virtualist. Jame, 319(5), 437-38. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2664528
9.New York University School of Medicine. (2016). Lacidem Care Group. Virtual practice. Funded by the AMA Accelerating Change in Medical Education Program. Retrieved from http://ace.iime.cloud/practice/