As Interdisciplinary Team Leaders, RNs May Improve Chronic Care Coordination

A new project will evaluate the effect nurse-led interdisciplinary teams have on chronic disease indicators.

Just before the New Year, I spoke with Donna Marvicsin, PhD, RN, PPCNP-BC, CDE, clinical associate professor at the University of Michigan in Ann Arbor, and she shared something that made me first laugh, but then made me pause and come to a realization about the complexity of patient care.

"I had a faculty [member] once tell me about my pediatric population, 'You know, Donna, it's not rocket science,'" she chuckled. When she said this, I immediately thought of my 15-month-old son. He climbs on top of our end table, stands up, tips it over, and falls. And then does the exact same thing again. And again. No, there's no rocket science going on there.

However, I'd argue that Marvicsin's present project—a new program that aims to improve chronic care coordination for underrepresented and underserved populations by using RNs to lead interdisciplinary teams—is by far more complex and difficult than actual rocket science.

With rocket science you apply the laws of physics, put some numbers into an equation, and voilà, you have lift-off. The laws of human behavior, if there are such things, are not so clear cut.

"Nurses get it," says Marvicsin. "They understand the nuances." And that, in part, is why RNs hold such potential to improve patient care by functioning as team leaders.

Moving Interprofessional Collaborative Practice Into the Community

The program Marvicsin is developing is a partnership between the University of Michigan School of Nursing and southwest Detroit's Community Health and Social Services Center, or CHASS, a federally qualified health center. The project is funded by a three-year, $1.5 million grant from the U.S. Department of Health and Human Services Health Resources and Services Administration.

Marvicsin points out that interprofessional collaborative practice had its roots in improving patient safety and quality of care in inpatient situations and settings.

"Where they are now is trying to migrate that work to the community primary-care-based setting," she says. "HRSA is really looking for sustainable models of interprofessional collaborative practice in primary care settings—true team-based care—and my belief is nursing, as a profession, is well-suited to lead these teams."

Marvicsin sees these registered nurse chronic care coordinators as conductors of an orchestra composed of physicians, pharmacists, support staff, and social workers.

"When a patient presents for a visit, all the information is there," she says, "all their lab results, they've been to ophthalmology, they've been to podiatry, etc. So when the patient walks in the room, we utilize the electronic health record to the maximum capabilities, and the patient and the provider can have this really rich discussion in timely fashion."

A New Captain of the Ship
I asked Marvicsin about a few challenges I'd anticipate cropping up with nurses leading a team of medical providers. The first was the physician's response. After all, they've been used to acting as the captain of the ship for decades.

"In a primary care situation, the physician truly doesn't have the time to do this coordination and to delegate," she told me. "Their heart's there, they're capable, but there's a shortage of primary care providers, and they're just pulled so many ways. They just don't have the time to add this on to all their other responsibilities."

Enter the nurse, who could take on coordination duties, but only if his or her role is changed from utility player to coach.

"RNs traditionally have been case managers," Marvicsin says. "I specifically titled this a chronic care coordinator, not a case manager, because I'm trying to change everybody's terminology and thoughts about that. What I view as the sustainability is [that] the RN won't be suddenly lost in the cause of answering the phone or of triaging. We can do that and do that very well, but they shouldn't be answering the phone. They should be doing so much more."

It's important to note that Marvicsin uses the term sustainability differently than we are used to hearing it used in healthcare. Rather than meaning a venture that is financially viable and self-supporting, she uses it to describe shift in culture.

"By sustainable I mean that that everybody gets comfortable with the new team," she says. "It's a shift in thinking that the whole production doesn't have to stop if the MD is not available to make a decision. Everybody's empowered in a true team to work on this project. So sustainable is really that I want the culture and thinking to shift in a permanent way."

Setting the Rules of the Game
The grant began in July 2015, and the search is on to find an RN to fill the coordinator position. Being a FQHC, CHASS can't compete with hospitals when it comes to pay. Plus, with a heavily Hispanic patient population, a bilingual nurse would be most appropriate. Marvicsin says she is confident the right person will be in place by fall 2016 and then the entire team will be able to hash out "the rules of the game" as Marvicsin calls them.

"Some of the managers are asking for the nitty-gritty details of the position. Well, the team has to decide that, I can't. I'm just the project director. If I come in and say you're going to do this and you're going to do that, that doesn't build the team," she says. "If this is going to be sustainable, it has to bloom from within, not from external control because external control means they won't own it. I want them to own it. So everybody has to agree that these are our positions and on the field, I'm going to throw you're going to catch."

The team will go through AHRQ's TeamSTEPPS® training and then keep tabs on specific metrics related to chronic diseases. Marvicsin says they'll watch for improvement in populations such as diabetes, hypertension, and hyperlipidemia.

"If we're doing a better job, the lipids will be down and the A1C will be down and all those chronic care indicators will shift," she says.

They'll also be assessing patient satisfaction by asking patients to rate their visit compared to those visits without the RN chronic care coordinator. And finally, they'll assess the team itself by doing pre- and post–project satisfaction surveys.