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New Primary Care Nursing Model

'Family Team Care' concept keeps RNs in a primary provider's exam rooms longer, producing life- and practice-saving results.

Almost a decade has passed since the staff at Hilton Family Practice in Newport News, Va., worked to transform a struggling primary care practice into a robust model of success.

The issues were typical: too many patients, too little revenue and not enough time. But by assigning the RNs more responsibility during patient visits, the practice managed to increase productivity, improve revenue, enhance patient care, and better both nurse and physician satisfaction.

"After becoming comfortable with the added duties and seeing the many benefits of FTC, I wonder why every office doesn't do this," said Cathi Pope, RN.

A nurse at the practice for 26 years, Pope left her job a year ago, along with family physician Peter Anderson, MD, creator of the Family Team Care model. The two now dedicate their days to spreading the good news that healing is possible for ailing family practices.

Slowly but surely, they're gaining converts. Health systems in four states have already undergone training in Family Team Care (FTC), and the U.S. Army has adopted it at more than a dozen community-based primary care clinics around the country.

"More and more primary care providers are realizing, 'I need to do this differently. Now, what's this?" said Pope. "Their ears are perking up."

Time Saver, Life Saver

Anderson had been toying with the idea for FTC for some time. But it wasn't until Pope, a colleague of nearly two decades, came to him in 2003 with notice of her resignation that he decided on the spot to try it.

"I got up my resolve and told him I needed to leave," Pope recalled. "My kids were going to college, and I needed to make more money."

Anderson's response wasn't what Pope had expected.

"He said, 'Don't do it! Give me six months. Just give me six months to try a new idea that I've been thinking about. I want to involve the nurses more in the exam room. If it works I will be able to increase your pay '" Pope recalled. "How could I say no?"

So began Project Team Care. Anderson instituted weekly staff meetings, compiled informational binders and began clinical refreshers with Pope and fellow nurse, Joyce Yates, RN, who had been with the practice almost as long as Pope. The physician assigned the nurses preset questions for common patient complaints, explained the rationale behind the queries and then moved on to preventive care screening by age group.

Pope and Yates took notes, asked questions and wondered aloud whether FTC could work. Anderson provided answers and reassurance.

"At first, we thought it was all too much," admitted Pope. "But it got better with practice."

At FTC's core is one simple philosophy: Everyone practices at the top of his or her license.

At Hilton Family Practice, that meant pulling the RNs away from the phone, where much of their time was spent talking with insurers, laboratories and pharmacies, and assigning them duties in the exam room beyond basic triage.

Anderson was determined to utilize the clinical knowledge the RNs offered. To Pope, it only makes sense.

"Everywhere else in medicine, nurses practice at the top of their license," she reflected. "But somehow, once you enter the office setting, that all changes."

How Family Team Care Works

To understand FTC, you first need to break down the typical primary care office visit into four parts: collecting patient information and documenting it into the chart; analyzing the information and conducting the exam; making decisions and developing a plan of care; and implementing the care plan and educating the patient.

While adaptable, FTC ideally assigns the first and last duties to the RN. The physician enters the room and conducts the second and third duties with the nurse present.

Compared with her previous work, Yates found FTC offered more patient contact and, consequently, more meaningful days.

"You really learned about the patients. It became much more personable," she said. "You were involved in their complete care. I really liked it."

Before long, FTC began to reveal other benefits. Freed from half his tasks, Anderson could see more patients in a day and fewer last-minute call-ins were being turned away. The nurses enjoyed the opportunity for professional challenge and growth. The team behind FTC felt more connected through the shared work. The charts were more detailed and complete than ever before.

Best of all, patients benefitted from two sets of eyes in the exam room.

"I can think of at least five patients whose lives were saved because of having the RNs more involved in their care," Anderson declared. "All of us get into ruts when we've seen patients for a number of years, and it's hard to get out of. The nurse offers a different perspective."

One 62-year-old man came in because of a lesion on his scalp. Through the nurse's preventive screening and the physician's targeted data collection, the clinical team discovered he also had coronary artery disease - a left main lesion, or in Anderson's words, "a widow maker."

In another case, a 35-year-old woman with diabetes dropped 30 pounds. A surprised Anderson congratulated her, assuming the patient had finally taken ownership of her previously out-of-control condition. The nurse, however, noticed and pointed out the woman's rapid heartbeat. The team checked her records and noticed a recent history of elevated pulse.

"I had totally skipped over that," said Anderson. "It turned out, the woman was on the verge of a thyroid storm, which can be fatal."

Another patient with a sore throat admitted to some chest tightness only when the nurse asked.

Anderson pursued the matter, and three days later the patient underwent heart bypass surgery.

"That's the way to practice. That's the ultimate," said Anderson. "Put a primary care provider with 2-3 RNs, and the patient volume could be 30-40 patients a day. The patients would receive top clinical attention, and everybody would be working at the top of their license."

Wanted: Primary Care RNs

That's Anderson's ideal, but he said he's learned a troubling truth while promoting FTC over the past year or so: RNs are disappearing from primary care.

"The economics of primary care have driven nurses out," he said.

Many practices seeking to learn about FTC employ LPN or medical assistants in what were traditionally RN roles. The Army, for example, matches two LVNs and one primary care provider for their FTC crews.

As Anderson sees it, nurses are neither being challenged enough nor making enough money in today's primary care practices. As a result, some are turning to hospitals and pharmaceutical companies for work. Others are leaving healthcare altogether. But under the FTC process, the exact opposite happened. As one of his RNs Karen Evans stated, "I had been working an interesting job at Anthem BC/BS for nine years but something was missing. Patients! I realized that I missed patient interaction and relationship. Although I never thought a primary care office would meet that need, the FTC model helped me meet that goal in a challenging environment."

And although the FTC team has trained the Army and other clients to adapt the model to involve medical office workers other than RNs, nurses' clinical education and training make them optimal team partners, Anderson said. "I was spoiled because I had RNs in my practice with me for years, and I thought that was the way it was everywhere," he said. "When they needed more money, the FTC model allowed me to pay for it."

He likened his team model to what exists in the operating room, surgeons and OR nurses working side by side to do the job expertly and efficiently.

"I don't know why in primary care we ever drove nurses out of the exam room," he reflected. "The doctor walks in and the nurse walks out. It kills us."

His beliefs are sprawled on his website banner. What is Family Team Care about? "Liberating physicians. Serving patients. Elevating nurses. Revitalizing healthcare."

"It's a win-win for everybody," he said.

Jolynn Tumolo is a freelance writer.

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The Family Team Care concept of care is excellent. Unfortunately most health care business models see RN's are an unacceptable expense. Instead, both private and hospital owned practices resort to CMA's who do not have a license therefore no scope of practice in most states. There is not regulation to protect the patient.

Mary Teague,  RNSeptember 21, 2013

This a fantastic model for all health care delivery systems to use - the model is a collaborative effort for physicians, nurses, and patients - conflict free collaboration is needed for the delivery of patient care!

Barbara Jachimowicz,  APRNMarch 02, 2013
Blackwood, NJ

This FTC model looks promising, and as a RN that has worked in private physician offices, I am well aware of the financial struggles. My only concern is for the practices that don't apply the full program. Instead of RNs' they use medical assistants or LPNs, which I don't think will give them the full benefit of this new model. I think it is very important to include RNs in strategic planning of private practices since they are the ones dealing with insurances, patients, pharmacies, and that makes them the perfect person to include new ideas on how to cut back on time and also be aware of what functions medical assistants can and can not do. Even clinics associated with hospitals don't use their staff to their full license potential. Having been a travel nurse for 3 years, I worked in many places and not using licensed staff to their full potential is a universal health care issue.

Pam  ,  MSNFebruary 27, 2013

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