Emerging Roles in Primary Care Nursing With Updates Following COVID-19

As today’s healthcare landscape continues to change, many health organizations are identifying opportunities for new roles within the nursing profession. At Cleveland Clinic, new nursing roles are emerging in a number of care settings and practice areas, including several in primary care.

At Cleveland Clinic’s 11th Annual Nursing Leadership Summit, which was themed, “Building a Culture of Health: New Roles, New Rules,” we featured four Cleveland Clinic primary care nursing experts who shared new ways nurses are bringing value to primary care settings. With combined experience of nearly 150 years, these innovative nurses presented a selection of new primary care roles that are now in action throughout Cleveland Clinic. Information has been added on this topic since the start of the COVID-19 pandemic.

Role #1: Advanced practice nurses in community care settings.

Advanced practice nurses (APRNs) are playing an increasingly important role in community care settings, especially with the projected primary care physician shortage ahead. For the past few years, Cleveland Clinic Community Care has been working to establish an innovative team approach to primary care that better utilizes advanced practice providers in managing a panel of patients to ensure supply meets demand.

Many advanced practice nurses in the community care setting are functioning as primary care providers where they see their own patients and provide care that ranges from prevention and wellness to diagnosis and treatment of common or complex diseases, as well as management of chronic conditions.

However, Cleveland Clinic Community Care has also been introducing another model that follows a ‘team of teams’ approach. In this model, physicians and nurse practitioners still serve their own patients, but they also have patients that they share, working together with other members of the care team, such as care coordinators and pharmacists, to collaboratively keep patients healthy.

To communicate the primary care ‘team of teams’ concept and help present this new culture to patients, Cleveland Clinic Community Care developed several patient leave-behind pieces that list all the caregivers on a patient’s team. For example, primary care physician business cards are now double-sided, including contact information for nurse practitioners and other caregivers on the back of the card.

The model of healthcare delivery has evolved once again in a world where social distancing and quarantine have become the norm. Telemedicine capabilities have expanded quickly, and both patients and APRNs and all caregivers have adapted to virtual visits, which are now being offered first unless it is an urgent or necessary office visit. Interventions can be ordered virtually, and more patients can be seen in a day. We have long had a medical assistant (MA) shortage, which is being alleviated by virtual visits because MAs can do more work efficiently on the computer. The idea that this will continue after social distancing is over is very possible.

Role #2: Telephone triage nursing in outpatient primary care.

Telephone triaging isn’t new to Cleveland Clinic as the Nurse on Call program has been in exisistence since 1991. However, in 2017, when population health became a major initiative of many organizations, it became clear that telephone triage in the outpatient setting was a necessary nursing role. So, a multi-disciplinary team began working with members of Nurse on Call to adapt Nurse on Call’s evidence-based protocols for all of Cleveland Clinic’s outpatient facilities – with the intent to standardize care across the enterprise and reduce overall dispositions to the emergency department (ED).

The new protocols included an assessment component, a list of triage questions to guide the nurse in providing recommendations on the level of care needed, care advice, medication and care management, and more. Creating a dynamic encounter for nurse, patient and physician, the program was first introduced at Cleveland Clinic’s Strongsville Family Health Center. It successfully improved encounter time-to-closure statistics and pointed to reductions in ED visits, showing a disposition to the ED in less than 8% of the callers, a number that was previously closer to 20% before the protocols were implemented.

Soon after, the team instituted a detailed and comprehensive system-wide rollout that included education through online learning modules, shadowing opportunities and hands-on training clinics. The program officially launched at all outpatient primary care locations in December 2018. After implementation, 60% of nurses in Cleveland Clinic’s regional ambulatory facilities noted improved caregiver confidence and felt the protocols were helpful for their practice.

Today, anxiety is very real as the COVID-19 pandemic has everyone concerned about their health and safety, and this 24/7 nurse triage has become even more important. These nurses are skilled at identifying a person who may be in trouble and getting them access to a provider if needed as well as assessing regular health issues that continue in the midst of the pandemic.

Role #3: Nurse practitioner and paramedic partnerships in the home care setting.

In just 4 years, Cleveland Clinic’s Medical Care at Home team went from caring for 700 patients to more than 2,000. With the tremendous growth, it became increasingly challenging for advanced practice providers to keep up with demand. Additionally, for patients who had been hospitalized, preventing readmissions was a top priority. Thus, the Medical Care at Home team began expanding the use of paramedics to provide in-home combination care between nurse practitioners and paramedics.

For high-risk hospitalized patients, the team developed a transitional care program. In the program, nurse practitioners see patients on the first in-home visit (within 5 days of hospital discharge). In addition to providing medical care, they also assess the patient’s home for social, physical, financial or other barriers that may affect a patient’s ability to care for themselves at home. They conduct a detailed medication review to ensure patients have the medications they were prescribed upon discharge. Depending on the findings, paramedics then conduct weekly patient follow up visits, which typically span one month. During the visits, paramedics communicate with nurse practitioners via phone to discuss patient care, issues or concerns, medication management, and more.

Additionally, paramedics also now see geriatric/elderly patients, patients who have difficulty getting to/from in-office appointments, and others who are experiencing problems such as anxiety, urinary-tract infections and confusion, for example. Due to the success of the program, the Medical Care at Home team has doubled the number of paramedics on staff..

This pandemic has highlighted the most vulnerable within our community — our frail elderly with little social support and those without access to transportation who need COVID-19 testing but are not able to drive to distant testing sites. They are all well served by this growing team of medical professionals. They have been called on to serve, making sure our most vulnerable are not falling through the cracks and are managing OK in their own environments. They are a new hero as we continue to take care of our population and rethink how we deliver healthcare.

Looking ahead

In the months and years to come, primary care nursing roles are certain to continue expanding and evolving. Likely, there will be ongoing opportunities for new roles in areas such as analyzing patient data for trends in things like patient acuity, as well as opportunities in patient scheduling, patient education, and more.