Nurse-Managed Clinics: Opportunity and Benefit

AAACN Viewpoint, Jan/Feb 2007 by Agbisit, Margarita D

The Voice of Ambulatory Care Nursing

Note: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

There are over 200,000 military members and their families in the Hampton Roads area, which includes Norfolk, Virginia Beach, Portsmouth, and Chesapeake. Virginia is known to be home base for the United States Navy's Atlantic Fleet (50states.com, 2006) and is one of the largest military concentrations in the world. Years of patient satisfaction surveys have shown that access to medical care is a major and constant health issue in this region. Common complaints received from the military staff and their families focus on the unavailability of daily appointments. Active duty military personnel, retirees, and their beneficiaries have expressed difficulty in getting appointments for their acute symptoms and chronic conditions.

In 2001, the concept of the nurse-managed clinic (NMC) was institutionalized to improve access to medical care. Using clinical practice guidelines and the joint Commission on Accreditation of Health Care Organization OCAHO) standards, two nurses, a clinical nurse specialist and a nurse practitioner, were asked to create the policies and procedures. The project took one year to implement; this was partly to ensure patient quality care and appropriate disease management, and identify the scope of care to be provided by the nurse clinic. New senior medical leadership presented disease management protocols to the Executive Committee of Medical Service (ECOMS), and once approved, the senior physician presented the NMC protocols and guidelines and discussed pressing issues with all the providers. With mutual agreements in place among the clinic providers and identification of the physician champion and nurse, the NMC was realized.

Qualifications of the registered nurse include one to two years' experience in the ambulatory care setting, experience with adult and pediatric asthma patients, diabetic education, physical assessment, and triage. Ambulatory care certification is encouraged but not required. The NMC follows specific protocols for patient care, with the role of the NMC nurse being centered on patient education. The nurse position is very autonomous, adheres to approved protocols, and involves critical thinking and prompt decision making. The NMC physician champion is consulted for advice regarding patients on a case-by-case basis. Crucial duties of the NMC nurse include daily calls, and utilizing protocols to interview and triage patients scheduled with the providers. Patients who fall within the parameters of an NMC visit are encouraged to utilize the NMC. For example, patients with urinary tract symptoms without other complaints can choose to keep their appointment with their provider or cancel that appointment and be seen in the NMC. The cancelled appointment slots are then available for patients who need same-day appointments.

Patients with the following conditions are seen at the NMC: diabetes, hypertension, hyperlipidemia, asthma, possible pregnancy, urinary tract infections (UTI), and attention deficit hyperactivity disorder (ADHD) screening. Patients diagnosed with diabetes, hypertension, hyperlipidemia, and asthma are referred to the NMC for education, followups, and tracking. Walk-ins are accepted for patients with UTI, pregnancy testing, and ADHD screening. Pregnancy testing has the highest volume of monthly visits to the NMC since its inception. The NMC is responsible for the initial teaching that emphasizes diet modification, avoidance of alcohol and smoking, exercise, and the early danger signs and symptoms of pregnancy expectant mothers may experience that warrant an emergency room visit. In addition to obstetric instructions, prenatal vitamins are given to the new mothers.

The NMC has been open for three years. About two to six months after the NMC began, NMCs were opened in other military medical clinics. A second NMC was opened at Boone less than a year later. It is well received and accepted by both providers and patients. The first-year data of the NMC visits are unavailable; however, Tables 1 and 2 show data from January 2003 to December 2003 and from January 2004 to October 2004 respectively (NMC File 2003-2004).

Survey Results

The importance of the data signifies that providers and patients are utilizing the NMC and that the need for its service is overwhelming. Random patient surveys were conducted from November 2001 to November 2003. Patients were asked what medical condition they were being seen for, if this was their first visit to the NMC, and if they were seen within 15 minutes of their appointed time.

One hundred percent of the chronic population patients (including those with diabetes, asthma, hypertension, and hyperlipedimia) strongly agreed that the care and education they received at the NMC will help them better understand and manage their health condition. Other aggregates surveyed were pregnant women and patients with UTI. One hundred percent of them said that the care and education they received at the NMC was useful and informative, and that service was prompt and quick. Ninety percent said they would use the NMC again. The remaining 10% of the population can be attributed to the pregnant women who do not attempt to get pregnant again. Most patients expressed gratitude for the creation of the NMC. The majority of the comments are summarized as follows: