1. Introduction: The Role of the Registered
Nurse in the Primary Care PCMH Setting
Susan Thorn, RN LNC
Masters in Organizational Management

2. Agenda Day One
 Reflective Pause
 Welcome
 The Chronic Care Model
 AAACN Standards of Practice
 Triage and Decision Making: Part One
 Lunch
 Triage and Decision Making: Part Two
 Quality: Activities, Outcomes, and Data

3. Reflective Pause

4. The Chronic Care Model
• Ed Wagner: The Father of Chronic Care
• “The current care systems cannot do the job”
• “Trying harder will not work”
• “Changing care systems will”
• The Chronic Care Model Talk
http://www.improvingchroniccare.org

5. The Community: Resources and Policies
• Mobilize community resources to meet needs of patients
• Encourage patients to participate in effective community
programs
• Form partnerships with community organizations to support and
develop interventions that fill gaps in needed services
• Self-Management Support
– Motivational Interviewing
– Diabetes Education
– Chronic self-care management

6. Health Delivery System Design: PCMH
• Assure the delivery of effective, efficient clinical care and
self-management support
• Define roles and distribute tasks among team members
• Use planned interactions to support evidence-based care
• Provide clinical case management services for complex
patients
• Ensure regular follow-up by the care team
• Give care that patients understand and that fits with their
cultural background

7. Decision Support
• Promote clinical care that is consistent with scientific
evidence and patient preferences
• Embed evidence-based guidelines into daily clinical practice
• Share evidence-based guidelines and information with
patients to encourage their participation
• Use proven provider education methods
• Integrate specialist expertise and primary care

8. Electronic Data Systems
• Organize patient and population data to facilitate efficient
and effective care
• Provide timely reminders for providers and patients
• Identify relevant subpopulations for proactive care
• Facilitate individual patient care planning
• Share information with patients and providers to coordinate
care (2003 update)
• Monitor performance of practice team and care system

9. The Current Problem…
• Rushed practitioners not following established practice
guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illnesses
• Right staffing models for chronic care

10. Enter the Registered Nurse!

11. RN Scope and
Standards of Practice
American Academy of Ambulatory Care Nursing

12. Goals and Objectives
• Definition of Professional Ambulatory Care
• Evolution of current ambulatory care and nursing practice
• The Practice environment
• The Science and Art of Ambulatory Care
• Ambulatory Nursing Roles
• Review of Standards

13. Overview
• First published in 1987
• Ambulatory Care is considered a specialty
• Ambulatory care nursing is dynamic
• Revisions to standards in 2009 through task force
• Six Standards address the six phases of the nursing process
• Ten Standards address professional performance

14. Definition of Professional Ambulatory Care
• Unique domain of specialty nursing
• Individuals, families, groups, communities, and populations
• Primary care
• Specialty care
• Non-acute community outpatient
• Telehealth

15. Conceptual Framework

16. Evolution of Ambulatory Care Nursing
• Drivers of change
• Redefining health care
• Primary Care is essential care
• Telehealth Services

17. Practice environment
• Primary Care is the cornerstone of:
 Internal Medicine
 Family Practice
 Pediatrics
 Women’s health clinics (OB/GYN)
 Telehealth services

18. Ambulatory Care as a Science and an Art
“Ambulatory care nursing is a practice.
Like nursing in general, a learned
profession and discipline requiring the
application of a core body of
knowledge from the biological,
physical, behavioral, and social
sciences. It is both a science and an
art.”- AAACN 2010

19. A Science of Practice
• Six step nursing process…..
1. Nursing assessment
2. Diagnosis
3. Goal/outcome identification
4. Planning
5. Implementation
6. Evaluation

20. The Many Hats of the Ambulatory Nurse
• Patient Educator
• Care Coordination
• Provider Support
• Telehealth Triage
• Mentor
• Leadership
• Staff Education

21. References
• Edward Wagner: The chronic care model and integrated care
https://www.youtube.com/watch?v=K-z6HjRkKSc&feature=youtu.be
• GraphicStock- www.graphicstock.com
• Scope and Standards of Practice for Professional Ambulatory Care Nursing, 2010 – 8th Edition
• The Chronic Care Model –Ed Wagner
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• You Can’t Scare Me…I’m a Nurse https://www.google.com/clipart