Open Forum

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

I started at a new job in an ambulatory specialty clinic recently. I do a lot of tele triage and have the same question on protocols. For example, should triage calls be sent directly to the RN or provider from the front office or should it go through the medical assistants first? I don't have an answer to this but I thought it would be a good thing to have a protocol on.

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

I started at a new job in an ambulatory specialty clinic recently. I do a lot of tele triage and have the same question on protocols. For example, should triage calls be sent directly to the RN or provider from the front office or should it go through the medical assistants first? I don't have an answer to this but I thought it would be a good thing to have a protocol on.

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

Hi Mary,

Currently every call goes through the nursing desktop and they decide what can be done by an MA. We are getting ready to implement SymtomScreen, which will tell our front desk staff how quickly a patient needs a call, who can take care of the need, etc. We will be using Clear Triage for the triage process. This eliminates a lot of the guess work and allows LPNs to do telephone triage (at least here in NC) because there are defined protocols and hard stops for various types of calls. These are two systems I highly recommend looking into if you have needs in this area!

I started at a new job in an ambulatory specialty clinic recently. I do a lot of tele triage and have the same question on protocols. For example, should triage calls be sent directly to the RN or provider from the front office or should it go through the medical assistants first? I don't have an answer to this but I thought it would be a good thing to have a protocol on.

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

I started at a new job in an ambulatory specialty clinic recently. I do a lot of tele triage and have the same question on protocols. For example, should triage calls be sent directly to the RN or provider from the front office or should it go through the medical assistants first? I don't have an answer to this but I thought it would be a good thing to have a protocol on.

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

Hi Stephanie,

I sent you an email! 

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------

Good morning Stephanie,

Ambulatory is a whole different world, for sure! I work in a primary care clinic within a small health system, but came from a primary care clinic in a large health system. Definitely the size of your health system will matter as far as the amount of effort needed to standardize the processes. 

1. We use the Schmitt-Thompson triage protocols, as others have mentioned for triaging. We have made some of our own protocols for things like refilling medications, UTI treatment, strep throat treatment, but we haven't used them enough (our clinic hasn't been open quite a year) for me to be comfortable posting them.
2. At my previous health system, any changes to standardization were nearly impossible to make happen. And if they did, it could take years for approval. Unless the changes were handed down from above us (we worked at a satellite clinic, so any changes came from the headquarter clinic locations). We are not standardized between clinics currently at my new health system. We have standardized some things - we use Epic, and have department level smart-phrases for different visit types that were copied from the other clinic to ours when we opened. However, the other clinic (established first), utilizes RNs differently than we do. As we grow, the nursing supervisor/RN representative from each clinic will review protocols and processes together as a group with Nursing Informatics reps, and work to align the processes based on best practice. We're not trying to be exactly the same, as different communities have different needs but we do want to align them as closely as possible. Once we get on the same page, we will make the standardized process available at all of the clinics.
3. At our clinic, blood pressure follow-up appointments (after high in office, or medication change) are scheduled with the RN. A walk-in blood pressure check with no symptoms might be put on the Medical Assistant schedule. Suture/staple removals are scheduled on the RN schedule if done by our provider, or if done elsewhere with clear instructions for removal AND our provider is the pt's PCP. The RNs do all of the Medicare Annual Wellness visits. Any walk-in patients with symptoms or who insist on being seen get placed on the RN schedule if no provider is available, for triage. We have a policy for RNs to manage INRs for warfarin patients, so all INR follow-up appointments are placed on the RN schedule also. We also do some of the more expensive injections, or injections that require assessment on our schedule - like immunosuppressant medication injections, sublocade.
4. What is included depends on the visit type. For INR patients, we initially do teaching on warfarin, and subsequent appointments monitor for lifestyle changes, and then counsel on any changes to warfarin dosing based on the INR. We only get the provider involved if there is an INR that is outside of what is covered on our protocol. For walk-in triage patients, we do an assessment on the patient based on the complaint, and then touch base with the provider if something is needed outside of our scope. Sometimes those patients are then worked into the provider schedule. Other times they might be instructed to go to the Urgent Care/ED. For follow-up blood pressure visits, we address dietary and lifestyle components with the patient. If the follow-up BP is WNL, then the patient leaves after we see them. If BP is out of range, then we work with provider for next steps before the patient leaves the office. 

I'm not sure if that answers your questions, but let me know if there is anything specific you can help with!

------------------------------
Adele Thomason RN
Tamarack Hlth Ashland Med Ctr
Ashland WI
(715) 292-3928
------------------------------

Hi Adele,

I'm wondering if you are able to bill for any of those visits?

Good morning Stephanie,

Ambulatory is a whole different world, for sure! I work in a primary care clinic within a small health system, but came from a primary care clinic in a large health system. Definitely the size of your health system will matter as far as the amount of effort needed to standardize the processes. 

1. We use the Schmitt-Thompson triage protocols, as others have mentioned for triaging. We have made some of our own protocols for things like refilling medications, UTI treatment, strep throat treatment, but we haven't used them enough (our clinic hasn't been open quite a year) for me to be comfortable posting them.
2. At my previous health system, any changes to standardization were nearly impossible to make happen. And if they did, it could take years for approval. Unless the changes were handed down from above us (we worked at a satellite clinic, so any changes came from the headquarter clinic locations). We are not standardized between clinics currently at my new health system. We have standardized some things - we use Epic, and have department level smart-phrases for different visit types that were copied from the other clinic to ours when we opened. However, the other clinic (established first), utilizes RNs differently than we do. As we grow, the nursing supervisor/RN representative from each clinic will review protocols and processes together as a group with Nursing Informatics reps, and work to align the processes based on best practice. We're not trying to be exactly the same, as different communities have different needs but we do want to align them as closely as possible. Once we get on the same page, we will make the standardized process available at all of the clinics.
3. At our clinic, blood pressure follow-up appointments (after high in office, or medication change) are scheduled with the RN. A walk-in blood pressure check with no symptoms might be put on the Medical Assistant schedule. Suture/staple removals are scheduled on the RN schedule if done by our provider, or if done elsewhere with clear instructions for removal AND our provider is the pt's PCP. The RNs do all of the Medicare Annual Wellness visits. Any walk-in patients with symptoms or who insist on being seen get placed on the RN schedule if no provider is available, for triage. We have a policy for RNs to manage INRs for warfarin patients, so all INR follow-up appointments are placed on the RN schedule also. We also do some of the more expensive injections, or injections that require assessment on our schedule - like immunosuppressant medication injections, sublocade.
4. What is included depends on the visit type. For INR patients, we initially do teaching on warfarin, and subsequent appointments monitor for lifestyle changes, and then counsel on any changes to warfarin dosing based on the INR. We only get the provider involved if there is an INR that is outside of what is covered on our protocol. For walk-in triage patients, we do an assessment on the patient based on the complaint, and then touch base with the provider if something is needed outside of our scope. Sometimes those patients are then worked into the provider schedule. Other times they might be instructed to go to the Urgent Care/ED. For follow-up blood pressure visits, we address dietary and lifestyle components with the patient. If the follow-up BP is WNL, then the patient leaves after we see them. If BP is out of range, then we work with provider for next steps before the patient leaves the office. 

I'm not sure if that answers your questions, but let me know if there is anything specific you can help with!

------------------------------
Adele Thomason RN
Tamarack Hlth Ashland Med Ctr
Ashland WI
(715) 292-3928
------------------------------

Hi Adele,

I'm wondering if you are able to bill for any of those visits?

Good morning Stephanie,

Ambulatory is a whole different world, for sure! I work in a primary care clinic within a small health system, but came from a primary care clinic in a large health system. Definitely the size of your health system will matter as far as the amount of effort needed to standardize the processes. 

1. We use the Schmitt-Thompson triage protocols, as others have mentioned for triaging. We have made some of our own protocols for things like refilling medications, UTI treatment, strep throat treatment, but we haven't used them enough (our clinic hasn't been open quite a year) for me to be comfortable posting them.
2. At my previous health system, any changes to standardization were nearly impossible to make happen. And if they did, it could take years for approval. Unless the changes were handed down from above us (we worked at a satellite clinic, so any changes came from the headquarter clinic locations). We are not standardized between clinics currently at my new health system. We have standardized some things - we use Epic, and have department level smart-phrases for different visit types that were copied from the other clinic to ours when we opened. However, the other clinic (established first), utilizes RNs differently than we do. As we grow, the nursing supervisor/RN representative from each clinic will review protocols and processes together as a group with Nursing Informatics reps, and work to align the processes based on best practice. We're not trying to be exactly the same, as different communities have different needs but we do want to align them as closely as possible. Once we get on the same page, we will make the standardized process available at all of the clinics.
3. At our clinic, blood pressure follow-up appointments (after high in office, or medication change) are scheduled with the RN. A walk-in blood pressure check with no symptoms might be put on the Medical Assistant schedule. Suture/staple removals are scheduled on the RN schedule if done by our provider, or if done elsewhere with clear instructions for removal AND our provider is the pt's PCP. The RNs do all of the Medicare Annual Wellness visits. Any walk-in patients with symptoms or who insist on being seen get placed on the RN schedule if no provider is available, for triage. We have a policy for RNs to manage INRs for warfarin patients, so all INR follow-up appointments are placed on the RN schedule also. We also do some of the more expensive injections, or injections that require assessment on our schedule - like immunosuppressant medication injections, sublocade.
4. What is included depends on the visit type. For INR patients, we initially do teaching on warfarin, and subsequent appointments monitor for lifestyle changes, and then counsel on any changes to warfarin dosing based on the INR. We only get the provider involved if there is an INR that is outside of what is covered on our protocol. For walk-in triage patients, we do an assessment on the patient based on the complaint, and then touch base with the provider if something is needed outside of our scope. Sometimes those patients are then worked into the provider schedule. Other times they might be instructed to go to the Urgent Care/ED. For follow-up blood pressure visits, we address dietary and lifestyle components with the patient. If the follow-up BP is WNL, then the patient leaves after we see them. If BP is out of range, then we work with provider for next steps before the patient leaves the office. 

I'm not sure if that answers your questions, but let me know if there is anything specific you can help with!

------------------------------
Adele Thomason RN
Tamarack Hlth Ashland Med Ctr
Ashland WI
(715) 292-3928
------------------------------

Hi Adele,

I'm wondering if you are able to bill for any of those visits?

Good morning Stephanie,

Ambulatory is a whole different world, for sure! I work in a primary care clinic within a small health system, but came from a primary care clinic in a large health system. Definitely the size of your health system will matter as far as the amount of effort needed to standardize the processes. 

1. We use the Schmitt-Thompson triage protocols, as others have mentioned for triaging. We have made some of our own protocols for things like refilling medications, UTI treatment, strep throat treatment, but we haven't used them enough (our clinic hasn't been open quite a year) for me to be comfortable posting them.
2. At my previous health system, any changes to standardization were nearly impossible to make happen. And if they did, it could take years for approval. Unless the changes were handed down from above us (we worked at a satellite clinic, so any changes came from the headquarter clinic locations). We are not standardized between clinics currently at my new health system. We have standardized some things - we use Epic, and have department level smart-phrases for different visit types that were copied from the other clinic to ours when we opened. However, the other clinic (established first), utilizes RNs differently than we do. As we grow, the nursing supervisor/RN representative from each clinic will review protocols and processes together as a group with Nursing Informatics reps, and work to align the processes based on best practice. We're not trying to be exactly the same, as different communities have different needs but we do want to align them as closely as possible. Once we get on the same page, we will make the standardized process available at all of the clinics.
3. At our clinic, blood pressure follow-up appointments (after high in office, or medication change) are scheduled with the RN. A walk-in blood pressure check with no symptoms might be put on the Medical Assistant schedule. Suture/staple removals are scheduled on the RN schedule if done by our provider, or if done elsewhere with clear instructions for removal AND our provider is the pt's PCP. The RNs do all of the Medicare Annual Wellness visits. Any walk-in patients with symptoms or who insist on being seen get placed on the RN schedule if no provider is available, for triage. We have a policy for RNs to manage INRs for warfarin patients, so all INR follow-up appointments are placed on the RN schedule also. We also do some of the more expensive injections, or injections that require assessment on our schedule - like immunosuppressant medication injections, sublocade.
4. What is included depends on the visit type. For INR patients, we initially do teaching on warfarin, and subsequent appointments monitor for lifestyle changes, and then counsel on any changes to warfarin dosing based on the INR. We only get the provider involved if there is an INR that is outside of what is covered on our protocol. For walk-in triage patients, we do an assessment on the patient based on the complaint, and then touch base with the provider if something is needed outside of our scope. Sometimes those patients are then worked into the provider schedule. Other times they might be instructed to go to the Urgent Care/ED. For follow-up blood pressure visits, we address dietary and lifestyle components with the patient. If the follow-up BP is WNL, then the patient leaves after we see them. If BP is out of range, then we work with provider for next steps before the patient leaves the office. 

I'm not sure if that answers your questions, but let me know if there is anything specific you can help with!

------------------------------
Adele Thomason RN
Tamarack Hlth Ashland Med Ctr
Ashland WI
(715) 292-3928
------------------------------

Good morning all, 
I am brand new to the ambulatory world and have started at a primary care/family practice clinic within a health system. Although I've been a nurse almost 20 years, I've never worked ambulatory before and have an opportunity to build this role. I have a few questions I would love some additional insight to:

• What are some nursing protocols you have in your clinic? Would you be willing to share?
• If you are part of a health system, how to do you standardized your processes, within the RN role, amongst your clinics?
• What is the process you follow to determine and schedule RN visits?
• For RN visits, what does this include?

I appreciate your help, collaboration and assistance!

------------------------------
Stephanie McDowell BSN, RN
Yuma AZ
928-336-6545
------------------------------