In my last post, I discussed the differences between how nurses are used in Acute Care Clinics in the community versus how they are used in corrections. Today, I would like to discuss the differences between the community and corrections on how nurses are used in Chronic Care Clinics.
Again, these remarks are based on a talk that Dr. Marc Stern gave at the Essentials of Correctional Medicine conference last year. It was quite a thought-provoking talk.
First, let’s define the difference between an Acute Care Clinic and a Chronic Care Clinic. An Acute Care Clinic is one where the patient has asked to be seen because of some problem or complaint. Examples would be “I have a rash,” “I have chest pain,” or “I am having a hard time breathing.” The patient is asking for a diagnosis (“What is causing this?”) or for relief of symptoms (“I want pain medication for this headache!”) or both. The key is that the clinical encounter is patient driven—the patient has asked to be seen—due to some acute symptom.
Visits to a Chronic Care Clinic, on the other hand, are scheduled by the medical provider to assess progress made in treating some chronic medical problem. These are scheduled months in advance and occur even if the patient is doing well. One example is a patient on blood pressure medications who is scheduled for a follow-up visit to see how the blood pressure is doing. Another example is a patient with hypothyroidism who is scheduled for a thyroid panel blood test to see if she is on the correct levothyroxine dose. Patients taking warfarin come to an anti-coagulation clinic to have their INRs checked. Each chronic disease, from COPD to rheumatoid arthritis, has a different set of monitoring tasks which are routinely done in a Chronic Care Clinic.
The key difference here is that chronic care visits are scheduled by the clinic, not the patient, and are expected to occur even if the patient is feeling well and has no complaints. Also, what will occur at the clinic visit is known beforehand. Usually, there is a checklist of tasks that are scheduled to be done each visit.
However, nurses once again tend to be used differently in Correctional Chronic Care Clinics than they are in the Community. But interestingly, the situation is exactly reversed from the Acute Care Clinic situation!
Community Chronic Care Clinics
In the Community, Chronic Care Clinics are most commonly run by nurses. The patient may not see a practitioner every time. Take the case of a Type 2 diabetic in the community. Three or four times a year, this patient is scheduled to come to the diabetes clinic for a Chronic Care visit. At that time, routine blood work (a Hemoglobin A1C, for example) is drawn, the patient is screened for diabetic complications (a foot exam, say, and blood pressure) and the patient receives counseling and teaching (for example, about the importance of the diabetic diet). All of these tasks are typically done by a community nurse. The patient may not see the doctor unless the nurse identifies a problem or unless the Chronic Care protocol specifies a practitioner visit. Otherwise, if the patient is doing well, the practitioner may only see them once a year. This is the community standard.
Correctional Chronic Care Clinics
However, as pointed out by Dr. Stern in his lecture, this is not how Chronic Care Clinics are typically done in corrections. In jails and prisons, Chronic Care Clinics tend to be run exclusively by practitioners. And using practitioners to do work done by nurses in the community tends to be inefficient for a couple of reasons (these are my opinions, not necessarily Dr. Stern’s).
- Practitioners tend not to do as good of a job with Chronic Care Clinic tasks as nurses do. Chronic Care, properly done, is a time intensive process that includes meticulously going through a checklist, answering questions and teaching. Practitioners (and I am including myself here) tend to go too fast. Nurses do a better job.
- Every minute a physician spends doing Chronic Care Clinic tasks typically done in the community by a nurse is a minute she cannot spend doing acute care evaluations and diagnostics she is better trained to do. This is a time management issue. The nurses will let the practitioner know if they find something during the chronic care visit that needs acute attention.
The practitioner, of course, should review the work done by the nurse in the Chronic Care clinic. The easiest way to do this is to use a Chronic Care Flow Sheet filled out by the nurses at the chronic care visit and signed off by the practitioner at review. And the practitioner should still be scheduled to see each chronic care patient periodically, say once a year. But other than that, the system will run more efficiently if nurses run chronic care clinics as is done in the community.
Interesting Article of the Week
Right in line with the theme of who should run Chronic Care Clinics is this interesting article:
Delegating responsibility from clinicians to nonprofessional personnel: the example of hypertension control. Margolius, et. al. J Am Board Fam Med. 2012 Mar-Apr;25(2):209-15. doi: 10.3122/jabfm.2012.02.100279.
In this study, the researchers delegated responsibility for Chronic Hypertension Follow-up to non-medically trained “Health Coaches.” These lay Health Coaches spoke to patients in the study frequently and counseled them on hypertension control and answered questions. These untrained Health Coaches were even authorized to titrate patient blood pressure medications according to a written protocol! Whoa! This was a “Mikey-Likes-It” type of study–after 6 months, the clinicians involved were asked how they liked the program–and most did, though some disagreed with the medication titration aspect.
I personally do not see those of us in corrections delegating responsibility for chronic care visits to a non-medically trained deputy. However, if practitioners are running your facility’s Chronic Care Clinics exclusively, I agree with Dr. Stern that it is perfectly appropriate to delegate that responsibility to nurses, as is done in the community.
Who runs the Chronic Care Clinics at your facility? Nurses, practitioners or a combination of the two? Please comment!
While the benefit of a ‘chronic care clinic’ seems obvious it is a challenge in a high transition small population facility (LOS avg. 11-14 days). Yet, we have some who do stay for significant periods of time (LOS avg. 9 – 18 mos; some up to 2.5 to 3 years. A clinic for anticoagulation would usually have 1 patient 2 – 3 times a year (visit every month). We do have scheduled medication reviews that trigger review of lab, vital signs, etc.
I have the same problem in my jails, Al. The rapid turnover makes scheduling Chronic Care Clinics a problem.
I appreciate your thoughts on the nursing profession, Jeff, but am a bit perturbed by the word ‘used’ in regard to discussion of the practice of a professional discipline. “Used” is a word reserved for equipment, inanimate objects, or maybe even service animals, but not professional colleagues. This comment is given with a smile…..
If we actually had chronic care flow sheets as you mentioned in your article, chronic care clinics would not be hard to do even in a jail, as long as you have an EMR that you can use to trigger all of those appointments, tasks, labs etc. We don’t have any Chronic Care Clinics or Flow Sheets here but we do similar things with forms and TRIGGERS. We give TB tests to each inmate who comes into the jail. We enter the date a PPD was placed on an inmate in his Medical Intake Screening form. CorEMR automatically schedules a task to read the test in 2 days and another task to repeat the PPD in one year. It the inmate is released in less than a year all of his future tasks are deleted. We provide Hepatitis A&B vaccinations here and to complete the full series of shots, takes 4 shots over a 1 year period. All the nurse has to do is enter the date on a form when a shot is given and the EMR schedules all future appointments and tasks as designed by the flow sheet. The nurse doesn’t have to put anything in the chart except the date given. You could do the same thing with building forms with triggers from your chronic care flow sheets and let the computer schedule everything for you. In fact, if you had Flow Sheets that you are willing to share for Chronic Care visits, I would be more than happy to create all of those forms myself, with the built in triggers and share them with anyone who uses CorEMR right now.
You are exactly right, Lorry. My tin-ear did not pick up the negative implication of the phrasing. I have revised the phrasing based on your suggestion. Thank you!
I will be in touch, James! Thanks.