Dr. Pelzman discusses the challenge of involving nurses and other healthcare professionals into the current scope of practice so they can do more of what they love.
Changing the scope of practice.
Suddenly we are faced with the concept of trying to figure out how to get somebody to be able to do a job that their job description doesn’t say they can do.
Sounds terrifying, yes?
As we have been rebuilding our interdisciplinary teams, we have discovered that bringing a lot of people together to focus on the needs of our patients leaves us with a long to-do list of jobs that need doing.
Once we have an interdisciplinary team that meets with the attending, the resident, nurses, care coordinators, social workers, registrars, medical technicians, all getting together to talk about our sickest and most complex patients, we come out of there with a list of new action items.
This patient needs transportation arranged. This one needs home services re-instituted, and longer hours with a home health aide, and some durable medical equipment. This one needs to be brought in for nursing education, to go over some nutrition information, to learn how to do fingerstick monitoring of their blood glucose levels. This one needs an appointment here within the week, and that one needs an ENT appointment in the next 48 hours.
Many Jobs to be Done
Now, it’s not like the people who we are giving these jobs to didn’t have plenty to do already. As we build this out, and we get more and more to do, we need to make sure we give everybody the tools and resources they need to efficiently and effectively get these tasks done for our patients.
Similarly, under our accountable care organization (ACO), patient-centered medical home (PCMH), and delivery system reform incentive payment (DSRIP) projects (and undoubtedly more to come!), we have a lot more boxes to check, and a lot more data we need to be able to collect and provide about our patients for the regulatory agencies supervising these projects.
Take our ACO, for example. As we’ve seen in our executive meetings, despite the institution of large highlighted yellow fields in the electronic health record, multiple emails, and endless education sessions for providers, we do miserably in our assessment of falls, documentation of vaccine status, counseling on body mass index, tobacco counseling, depression screening and follow-up, dilated eye exams, interventions for blood pressure out-of-control, and on and on and on.
Apparently you can teach doctors a lot of things, but it’s really hard to get them to click a lot of boxes that they don’t see as really helping their patients.
As it stands now, the providers are all very frustrated with this “stuff”, and we feel we’re all alone. Everything depends on us to get this done right, and for the most part people are telling us they feel sort of hopeless about the probability of success.
But what if we turn this around, and turn it into an opportunity to create a better office visit, with a way to collect this data and also take better care of our patients?
Our nurses are itching to do more. They want to provide actual care for patients, not just spend time on the phone doing prior authorizations and refills. They want to talk to our patients, care for them, give them advice, teach them about their diseases, and really become part of the team. This has been missing in the ambulatory setting.
And our medical technicians have told us they feel sort of like automatons, scooping up a patient, doing vitals, depositing them back in the waiting room, then on to the next, sitting sometimes for long stretches of time staring at a computer screen waiting for the EHR to flash red showing that someone new has checked in.
These are all trained professionals, and they’re desperate to do more.
Changing the Current Situation
Right now, the flow of an office visit at our practice goes something like this: the patient arrives and is checked in with the various systems at the front desk, given an identification band with their name, date of birth, and medical record number on it, and told to have a seat in the waiting room.
The medical technician sees that a patient has arrived, and brings the patient back to a vitals station to measure blood pressure, pulse, respiratory rate, temperature, oxygen saturation, height, weight, and pain score.
The patient is then summarily returned to the waiting room, to await the impending glorious arrival of the physician or nurse practitioner.
And they wait. And wait. And wait.
Maybe we could put this downtime to some good use. Use it as an opportunity to engage patients in their health. Find out what medications they are taking. Issues with compliance, cost, side effects? What referrals do they need? Anything else they are doing for their health? Do they need some more help at home?
And then we could add on those screening questions we need to collect. And actually get the answers we need.
Administering the depression screens through an electronic interface is easy, and we could get answers from all our patients to those two simple questions, which would bring us quickly to 100% compliance with one of these necessary measures.
Having someone review their health maintenance field in the EHR, and update it, in advance of that office visit, even setting up orders for necessary vaccines, mammogram, or even colonoscopy, would simplify life and get us into compliance faster than we are depending solely on those recalcitrant physicians.
Then, by the time the patient arrives in the exam room for their visit with me, I will be all ACO/PCMH/DSRIP compliant, and a lot of busy work has been done that actually can lead to better care for patients. By simply signing a couple of orders that have been set up for me in advance, more healthful stuff will likely get done for our patients.
“Scope of Practice” Barrier
While we have been trying to get our registrars, medical technicians, and nurses more involved in the care of our patients in the ambulatory setting, we’ve been bumping up against the “scope of practice”, a strict set of rules that closely defines what a particular employee can and cannot do in our institution.
But it turns out that once you show senior leadership how this “stuff” isn’t going to get anywhere near the levels that they need to demonstrate based solely on the box- clicking abilities of us wayward physicians, then everyone’s quick to allow a change in the scope of practice to come about.
We have already described this change to senior leadership, that involving the remainder of the staff in these activities, giving them the opportunity to counsel patients and recommend healthy activities, referring them to nutrition and teaching them about their diseases, going over their medications and how to take them, gets everyone excited, and it’s a win-win situation for everyone.
So they are suddenly fully on board, anxious to modify the scope of practice with a new vision, a new set of goals in mind.
Good for the patients. Good for the rest of the staff that now get to be more involved in true care rather than just doing a bunch of rote tasks. And good for the providers — maybe fewer boxes to click and most assuredly healthier patients.
This new scope of practice could move us closer to that vision of a healthier practice of medicine.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.