Good afternoon. It's great to see everybody today. Welcome to cardiovascular nurse role and responsibilities webinar. And this is a initiative that the MedAxium team, as we were kind of thinking about 2023 and some of our initiatives, we really wanted to create a series of tools and resources for all of you focused on workforce stabilization. There's been so much disruption, so much turnover. And so what could we do to help all of you? And one of those things was a little bit of a back to the basics and helping us understand best uses for our teams based on license level, but also the introduction of several offerings for standard learning for those teams. So we're going to talk a little bit about all of that today and really focus on the role of a cardiovascular nurse. I'm joined today by Jenny Kennedy, who is our VP of care transformation and our nursing expert. In fact, many of you may have joined some previous webinars related to nurse navigator, but she's joining me today and we're really going to cover the role of that ambulatory nurse and cardiovascular and some of the different roles and responsibilities. And I'm Ginger Beesbrock, I'm the EVP of care transformation with MedAxium. So again, thank you for joining us today. We'll probably start with a little bit of housekeeping. And so with our current Zoom platform, you have the ability to find a link to access your presentation slides, as well as send any questions over into the Q&A tab. And what we'll do is we'll work our way through the content today. And then the time we have left, we'll open it up for Q&A at the end. So I want to talk a little bit about just staffing overview and a little bit of some definitions, if you will. So a little bit related to nursing. And this is where I think it's important that we understand kind of the different roles, the different licenses and the different levels of education. So for a registered nurse, that education right now is either a two-year or a four-year program, sometimes can be both an associate's and a bachelor's degree. There is a license required and the license that is provided at the state level. The scope of practice is based on being part of an approved training program, an exam, and again, is defined by that license at the state level. And then practice considerations would be the ability for them to make clinical decisions, but through algorithms and protocols. So kind of follow through on tasks they can, and we'll get into some of the additional actual responsibilities here on the next slide. Licensed practical nurse is usually a one to two-year program. That's also a licensed role, licensed at the state level. And you can see that some of the additional considerations for scope of practice and practice considerations are very similar. Certified medical assistant is a three to six-month program. Most states do not offer a license for this. There's really no scope of practice for that role. It's a non-licensed role. And the way that typically it's thought of is that it's a role that can follow through with directed tasks that really does not and should not include any decision making. So great at calling back normal labs or providing direct to patient education, but when it comes to interacting or providing clinical decision or clinical interviewing, that's really not a role for a medical assistant or the type of work. And then some of us in our clinics also have certified nurse assistants. This is also a very different and usually a minimal of 120 hours of training. So if you do the math on that, that I've got to do it quick. That's three weeks. That's a three-week full-time program. Some states offer license, but usually it's not a licensed role. Scope of practice has to do with the training program and a skill competency exam and then practice considerations. And that the training for this role is usually focused on patient assistance and assistance with activities of daily living and basic patient support. So we're not going to get into CMA and CNA today, but I wanted to start with a bit of an overview because oftentimes I have found that sometimes the role or the word nurse, we might apply to any of these roles when really what we're referring to is registered nurse or licensed practical nurse, which are both licensed roles and both have a defined scope of practice based on that state license. So roles need to be developed based on care objectives and license allowances. So we've talked about license. The next area we're going to talk about are the different roles and responsibilities. And if you've, many of you have probably been in on my team-based webinars in the past, I'm a big fan of defining roles and responsibilities based on license and mapping it out. Because when you do that, it creates a framework for you as you start to add new roles or you get some scope creep, you can kind of go back in and readjust. Is this the right responsibility for that role? So in this case, to me, this is fairly high level. I'm not going to go through all of this right now. Many of you may have seen this before. This is one of our common frameworks that we use. But physicians have a set of responsibilities based on their license. APPs have a set of responsibilities. RN, LPN based on their license can have a set of responsibilities and so on. And so the goal is really to understand what do our patients need? What are those care objectives? And then bringing that into the actual responsibilities of the different roles within our teams. Go to the next. I want to provide you a little bit of data. So oftentimes people will ask Ginger and Jenny, how many nurses should I have? I have 10 cardiologists. How do I know how many RNs or LPNs or MAs should I have? So I always say, well, let's see what our data says and let's see what the average is across the country. But I think there's an additional factor in that. The additional factor in is the number of active patients or the patient panel size for your group. And this will create an environment where if you are in the top quartile of the number of active patients per cardiologist, in order to support all of the care that those patients need, you probably are going to be or should be in the top quartile of staffing. If you're in the middle quartiles, 50th to 75th or 25th to 50th, you probably should think about the middle quartiles for staffing. And if you're in the lower quartiles, again, lower quartiles for staffing. Now I'll also flip that to say, if you're an organization that is looking at how do I support or enhance the productivity of my clinician team, my physicians and my APPs, and we're trying to do that in an environment where we are staffed at a low quartile, we want to get our physicians and APPs to a higher quartile, it's a team-based sport. So our need for nursing support, nursing role, way we use our MAs, all of that, our schedule, the whole caboodle goes along with that. So I wanted to start by kind of introducing you or reminding you of that patient panel concept. Now, if you go to the next slide, Jenny, and you all have this in your handout, but this is the current staffing ratios for, this is the RN FTEs, which you'll see the median here is 0.66. So for every three doctors, I have two nurses. And this is really focused on an ambulatory nurse. So not stress nurses, but the nurse in your nurse triage, your team-based nursing, and any other potential nurses that you have, RNs that you have on your team. Jenny, if you go to the next one, this one is a mix of LPN and MAs. And then the third one, I pulled it all together for clinical staff. So you've got the data, you can go back and kind of do that math in your own area and understand, are we overstaffed, understaffed? And what does that look like? But I think the answer to the question, how many do we need? And I'm going to walk through this towards the end again, really has to also, you have to think about your patient panel and the number of active patients that you're managing. All right, so let's start to walk through some of these roles and responsibilities. I'm going to walk you through four areas, and then I'll transition over to Jenny, and she's going to hit some of the additional considerations, if you will. So we'll talk through nurse triage, team nursing, nurse visits, so those are face-to-face visits with patients, and a nurse closer role. These are all very common, and I would advocate probably necessary roles within a contemporary cardiovascular practice. So team triage, nurse triage, so a few things to think about. Number one, they feel clinical calls from patients. So when our patients call in, they take care of those clinical calls. They also manage patient walk-ins. So when patients walk in off the street with a clinical question, they don't have a visit, we use our nurse triage team for that. We need real-time availability. That is so important in our ability to manage our patients and keep them out of the hospital and out of the ED, is our ability to manage those clinical questions in real time, and then an ability to triage patient complaints to develop a disposition. So maybe we still need to send them to the ED or direct admit them, maybe we need to bring them into the clinic, or maybe we can manage some of those pieces over the phone and get some answers that way. So typically how this team is set up, or this role, I'm going to call it a role, is that it's a person or small team, depending on the size and the number of calls coming in, that are designated to manage these calls. I have a five to ten minute rule, and I'm going to explain what that means in just a minute, but the goal is that we can quickly, efficiently, and we're available, and that is the art. That is a challenge to create those efficient, available, accessible part of our team. So let me talk, tell you a little bit about how this can happen. I think there's a couple different options for the way we deploy this role, but before I get into that, the key to this role are predefined guidelines, and so creating an environment of which patients, when they call in, which complaints need to go direct to the nurse, which complaints can we manage versus into an in-basket that's still managed same day, and then when we flip into how is that nurse going to triage that information, we need additional protocols and guidelines to walk them through the different types of complaints and create a framework for them to follow as they evaluate or assess that patient and develop a disposition. But at a minimum, well we need both of those things, but to start with, we need to arm our operators or wherever that initial phone call lands in helping them understand which one goes directly to a nurse that needs to be verbal-to-verbal, like a direct pickup, or which ones might be able to put into more of a holding pattern for the nurse to then follow up, but again, still same day. This is just an example of that. So example number one, how do we set these models up? The first model is a nurse-first model where all clinical calls are answered by the nursing team. So patient calls in, maybe I'm not a huge fan of long phone trees, but maybe one of the phone trees is if you have a clinical question or a symptom, you hit number two and number two goes directly to the nurse team. That team needs customized clinical directives that's tailored to the patient population, and we have an example of that that we'll share. And the goal of this is that they may function as an extension of the care team. So we create an environment where they know how to, you know, disposition-wise, which ones do I turn over to the clinical team, which ones do I manage right now, and how do I best manage that? That's where my five to ten minute rule comes in, and that has to do with the patient has a question. Now the urgent questions, having a symptom, concerns for instability, that needs to be escalated right away. We need to figure out ED, ambulance, indoor clinic. But if it's a question about patient was in yesterday and got a new med and then questions about the new med or maybe they got a rash, which of those ones are managed by that RN that's part of the triage rule that day, which ones go back to the team nurse, that's where my five to ten minute rule comes in. If I can manage that question in five or ten minutes and it doesn't require escalation to the attending physician or the cardiologist of record, I usually tell the team go ahead and manage that. Because when we start handing things off for simple questions, that's where we create, it's not a great experience for our patients and we spend more time handing things off and documenting than just taking care of it. If it's more than that and it has to be escalated back to the physician of record, then I usually say then go ahead and transition that question to the team nurse. We've got the triage nurse that's taking that initial call and then we've got the team nurse and I'm going to walk you through that team nurse role here in just a minute. We need also for this role documentation in the EMR. We need protocols for what needs to be documented, how they documented, then we need an escalation process because if I have a patient that has a need right now, I need to know which physician do I call, how do I manage it and what does that look like. Then finally, metrics to be monitored, call volumes, first answer, message turnaround. Again, this is a scenario where I may have a set of one or a small set of nurses that this is their role. They are the team nurse for the triage, or I'm sorry, they're the triage nurse team for our practice and that's their role. They function in those daily calls that come in and they disposition the clinical, they answer what they can that's easy and short and they disposition the rest, escalate what needs to be escalated and managed from there. The second example of triage, if you go to the next one, is additional areas for those non-urgent and this is where we take our team nurses and we create a rotating. I might be a team nurse and I work with Dr. Smith and Dr. Johnson. Again, I'm going to walk you through what that role is here in just a minute, but on Tuesdays, I also manage the nurse triage line. I will go ahead and I'm the one that picks up the phone or I'm the one that goes into the queue and pulls out those and then triages them or dispositions them, manages the easy stuff, but my role is kind of a shared role. I don't have full-time triage nurses. We have a team of nurses that we all rotate through that role on a daily basis or a weekly basis or whatever that might look like. I'll be honest. Actually, if you go back, Jenny, if you're building this from scratch, I believe that the better model or both models will work just fine if they have the tools that they need. I like the rotating model and the reason I like the rotating model is because that nurse also understands all the team functions and it just, that RN role is a hard role to do day after day and so there's just days where you're not connected to that phone and so it just creates a nice balance and so having that as a shared rotating role I think works really, really well. A couple other things you need to think about though. The other option is rather than having the nurse take all those calls, so dial two and you get a nurse, you get the operator and then the operator triages the non-urgent versus the urgent calls and it goes into a queue. You'll have, again, the urgent ones need to go directly to the nurse, the non-urgent ones can be a new task, a phone encounter that then gets routed to the work queue that then in between the urgent calls that nurse triage role is working their way through those where they go in, they see what the patient called about, call the patient back or manage it from there so it kind of creates a level of that nurse isn't going to be the first answer for all of them just those that are urgent. Now the key piece of that one is we've got to have a good template or escalation policies for our operator team or whoever's answering those initial calls so they know how best, which ones need to be an urgent face-to-face warm handoff or which ones can be put into the queue to be managed later in the day. Go to the next slide. Like I said, effective nurse triage begins with good clinical direction, so we're happy to provide this example and we'll, I don't know, Jenny will figure out how to get that into the out to everyone, but this is an example. What we advocate is that you build these for your own, you can take our example and kind of work that through, but you need a physician champion, you need a nurse champion and a leader and administrator and you need to land on some triage protocols based on a symptom, what questions should the nurse ask the patient and then what do we do with that information, which patients need to be escalated on an urgent basis and which ones can be managed through an in-basket task or a question that way. Those pieces are really important. Additional considerations, I sort of talked through these already, so triage, team, that that's all they do versus a team nursing role, I kind of like the one that rotates through, escalation procedures and easy communication. They need to have a phone a friend, so APP of the day, position of the day. If the attending of record is not available, they've got to have somebody else they can get a hold of to manage that patient. Then call center team versus nursing team, so I have seen where we've set this up where we actually have that R and triage team sits in the call center with the operators. That's a great way to hand things off, a warm handoff and clarify and ask questions. Also seen it where their facility-wise, their location is with the nursing team. I don't think there's a right or wrong, I've seen both of those work really well. Then when it comes to how many, well your volumes will dictate your staffing, so the number of calls you come in and then whether or not this is a dedicated role. That's just one of those things that you kind of have to play with to understand and be able to monitor call volumes and then understand the amount of time it takes to process some of these calls, so it's a bit of a moving target. I think the key is to stay close to your team with that. Here's just a few performance management metrics that we provided for reference. Transitioning to team nursing, so team nurse triage is really those urgent clinical questions and needs that come in. Team nursing is focused on the following objectives. The first one is those routine clinical patient calls and portal questions, so this is not the urgent stuff. These are the, I had labs a week ago and wanted to follow up on those. I have questions about this medicine. I have questions about this diet. I have any number of questions about this procedure. Those are the sorts of routine calls that this team will manage. They also manage results review and communication. Now, there's two levels of this. And at a minimum, they manage the post-physician, meaning that the physician has reviewed all of the labs or test results that were ordered by that physician. And the follow-up communication, they text over to their team nurse, and the team nurse then reaches out to the patient and manages next steps and coordinates all of that care. The pre-physician is where we actually take that team nurse, attach them to the physician in basket. Now, they cannot sign off on these things for the physician, but they can go in and review those results as they come in, and in essence, triage those results. So tee them up for physician review that can go a long way to make the physician more efficient. And also allow the nurse to kind of understand, because again, these are a part of all of those active patients, what some of those patient needs are. So there's a level of, for sure, post-physician, where they're following up on those tasks that after the physician reviews those diagnostic results, sends back to the nurse with a nurse note. We need, can you call Mrs. Smith and have her get her, tell her to double her lysinopril or get her CHEM 7 next week. The pre-physician is where I'm literally going through, oh, here's a CHEM 7 that came back on Mrs. Smith. Oh, why did doctor order it? I went back to the note. Oh, ordered it because we doubled the lysinopril. Okay, results are no, everything is the same as the last one. I write a quick, the beginnings of a result note. Mrs. Smith had a CHEM 7, one week post starting her lysinopril. CREAT's no different from this CREAT, potassium is stable, sends it over to the physician for follow-up and ultimate sign-off. So if you imagine that takes a lot of the workload off the physician when it comes to some of that documentation, because it starts that clinical documentation already. So it really is a great role for efficiency, but it does require then more nursing teams. So if you get, you go back to that patient panel, we're managing a lot of patients and I'm asking my physicians to have a higher patient panel if we support through different people on the team and that nurse is a key role of that, this is a great way to potentially make your physician or provider team more efficient and not have to spend as much time in their in-baskets. So both pre and post. The next one is the patient paperwork, disability, return to work papers, things like that, usually falls within this team member. Patient education, whether that's telephonic education or going down to clinic, maybe we have a new antiarrhythmic start or we have a new heart failure diagnosis, the team nurse is a great one to tee up that education. The other reason why that's a great role for that person is because oftentimes those are the same patients that call back with questions. So we get to know those patients and that creates an environment where not only does the nurse connected with the patient, the patients know that Ginger is my nurse that works with Dr. Smith and they both take care of me. So it creates a really nice environment. And then finally care coordination. So sometimes periprocedural care, pre-procedure care coordination, or coordination of care between different specialties can just help manage all of that communication and understanding what's happening with those patients. And then I mentioned already procedure planning. These are all objectives that can fall under that team nursing role. So some structure requirements. Number one, standard work for patient callbacks and documentation. Number two, in-basket structure. So how are in-baskets gonna be set up? Do you want that nurse in that physician in-basket and we need to then connect them. Again, they're not there as a surrogate to sign off. They can't do that, but they can review things and then start some documentation around what they're reviewing for that physician or clinician to ultimately sign off on. Do you want individual in-baskets where I have my nursing in-basket? Do we want group in-baskets where maybe the small pod, several physicians, a couple of nurses, we all share one group. You can get creative with your in-basket architecture to help follow the flow of your data as well as the role of your nurse. So make sure your nurse role dictates your in-basket structure. Don't let your in-basket structure dictate the role of your nurse. The third one is nurse to physician communication expectations or physician to nurse communication expectations and accountability. So if we're gonna manage things through in-basket communication, what's the turnaround time that we need? Are there other opportunities to manage some of that communication? For the nurse to go, Dr. Smith is in the clinic today and I'm gonna go sit with Dr. Smith and we're gonna work through some of these questions. A lot of that is, I like in-basket because it creates an environment for paper trail. It's also efficient. But at the same time, many of us are living in an environment where we've had to kind of remove the nurse from the care area just because we don't have enough space. It also allows the nurse to probably work a bit more efficiently, but we don't wanna disconnect the nurse from feeling like they're part of the team. So anytime we can get them into that care area, that's really helpful. And I'm gonna talk about nurse closer here in a few minutes and that's another great way to do that. And then finally, minimizing non-nurse functions, whether that's scheduling, script refills. Now, some of our states do require nurse to be that script refill, but certainly scheduling some of the phone call, normal labs, some of the normal sorts of phone calls can be managed either through email, not email, but portal communication, snail mail communication, or utilizing MA or other people on the team for those callbacks. Really using your nurse for those callbacks that require clinical decision-making, education, care coordination, those kinds of things. Okay, so back to the how many nurses do we need? So this is an example of a process, if you will. Now, again, it is a bit of a moving target because you need to understand it makes a difference if we're gonna do, if we're rolling team triage in with team nursing, if we're gonna add, I'm gonna talk about nurse closer here in just a minute, if we're gonna add nurse closer, if we're doing a bunch of nursing visits, all of those things make a difference. And so you need to understand kind of the type of work that that team member's doing and the volume of work that that team member's doing based on the type of patients they're taking care of. So this is a great example where I pulled in electrophysiology, interventional and non-invasive cardiology, I pulled in their patient panel sizes, and then I started to identify how much nursing time, how much FTE is needed for these different physicians based on the type of patients they're managing, the care objectives that need to be managed, and then the type of responsibilities that I'm asking this nurse to fulfill. Again, there's not an exact science, but those are the considerations that you need to bring into this. And you can start with data. I would, if you're trying to answer that question, this, I would go in and pull those panel sizes. And then I would also go in and understand what's happening. So in electrophysiology, there's a ton of pre-procedure, peri-procedure planning with those patients. The nursing ratio is gonna be higher. Interventional, there's a fair amount of pre-procedure, peri-procedure planning, probably not as much as EP, but definitely more than clinical cardiology. Clinical cardiology, we're managing more longitudinal patients, but probably 80% of the patients that come into clinical cardiology are never gonna call your nursing line or have to talk to the team nurse. There may be some lab results that need to be followed up on, but we're not doing a lot of care coordination with those patients. You will for a small number. Heart failure, I don't even have on here. The ratio of nurse to physician in a heart failure clinic is probably close to two to one because of the amount of care coordination, education and telephonic support that those patients need. So those are the sorts of considerations that you bring in when you start to kind of define where is our nursing role and how much nursing FTE do we need compared to our physician team or clinician team. Go to the next slide. The last two areas I wanna talk about are nurse visits. So the first one, nurse visit, what is it? Well, it's a low acuity check-in, things like blood pressure checks, wound checks. Maybe a patient that has no paroxysmal AFib had some symptoms we're gonna do an EKG or maybe we need to do rhythm follow-up or rhythm surveillance. Nurse visits are not a substitute for poor provider access. So please, if you can't, I mean, can't get patients in, we need to make sure we have a plan and we're working on that. But nurse visits really should be focused on those surveillance, low acuity check-in type management or functions. Plan of care documentation must be clear. If I'm gonna bring the patient back for a blood pressure check, I need the clinician, physician, APP to outline what needs to happen with the patient. Otherwise, we took a 10-minute nurse visit and we turned it into a 40-minute function because I gotta go chase down somebody to find out what to do because the blood pressure is 142 over 84 and maybe we need to adjust something. Make sure that plan of care is in place. And then finally, standard work for visit documentation, billing and escalation. The last one I'm gonna cover is Nurse Closer. The idea here is to provide team support during face-to-face E&M visits through a nurse role, an RN or an LPN, so a licensed nurse. They can be available to provide patient education, whether it's disease-specific, procedural care or care coordination. And then there can be available for order entry and follow-up management. It's an area where you can go a long way to improve efficiency. The nurse doesn't need to go in at every visit. In fact, in this sort of an environment, we would recommend that they don't, but they're readily available. So physician goes in or APP goes in, sees the patient, oh, it's a new heart failure, come out. Ginger, can you go educate the patient on a heart failure diagnosis? And then we can go in and do a follow-up. Educate the patient on a heart failure diet, whatever we're using. Patient was just found to be in AFib and need to start an anticoagulant. Ginger, can you go in and educate the patient? Ginger's also sitting at the desk, so when the clinician comes out, we need an echo, we need a follow-up visit in three weeks, and I need a chem seven in a week. Ginger would have the ability to go in, put those verbal orders in, execute those orders. They still need to be signed off, but where the benefit comes in is that all those orders get put in in real time. So when the patient walks up to the front or the scheduling function, they're all in there and those things can be scheduled. And then it allows the physician, stuff is in there, they just go in and sign off on it and then they can move to their next patient. But it allows those orders to be executed so that the rest of the functions can happen. So that's really where, and then the other value of this is it brings that nurse role back into the clinic on the days that the physician that that nurse works with, oftentimes these are gonna be the patients that call in with questions. The nurse, he or she were in the clinic and they maybe met those patients. It just creates a nice transition or a nice handoff in relationship building for the patient. Quick piece on nurse order entry and I'll start with the disclaimer. Local policy may vary on ability to execute orders. So we can put them in, but can we actually execute them? The final signatory is always the provider. But sometimes because it's put in by a licensed nurse, we have the ability to execute again, which allows the scheduling to happen and the things show up on the after visit summary and all of those processes that need to happen before the patient leaves the building. Provided just a very basic workflow for that. But again, you need to go back to your local policy and make sure that that's something that is allowed. So with that, I'm gonna transition over to Jenny and she's gonna walk you through some additional great opportunities for use of licensed nurses in our CV practices. Thank you, Ginger. And thanks for going over those four very important roles. And I think what I wanna do is spend some time talking about what we would call non-traditional nursing roles. And it is a very challenging environment that we are in right now, but there's also an opportunity to rethink where our nurses fit. And often we hear in organizations across the country, let's work our nurses to top of scope, but we've gotta create these opportunities, policies and practices to support that. So I'm gonna go over a couple of unique kind of scenarios and ways that we can really leverage nursing within cardiology. The first one being our high-risk medication clinics. And you've probably heard about these and sometimes nurses are partnered with an APP or a pharmacist and looking at the traditional one, anticoagulation, that's not new to cardiology. But with the limited access to providers and the amount of time it takes to coordinate these frequent medication titrations, adjustments, questions and education, we really have higher frequency touch points with our patients, especially around heart failure. Clinics that are managing GDMT for HFREF and or heart failure, fluid volume management, hypertension, hyperlipidemia. These types of clinics are really supporting the use of RNs and the literature supporting their effectiveness to really work to combat this chronic disease management in our population. So really in terms of guiding principles for these types of clinics, you really need to have the right specially trained nurses to do this. And it's not just initially, it's ongoing. We need them to be up to date. We need them to be experts and they need to keep up with the evolution of the disease and any updates in the guidelines. And then of course, this always has provider oversight. So we wanna keep our nurses within scope and it's a partnership. They are an extension of the team and that's done by using these multidisciplinary teams to create algorithms and agree upon what medication changes are going to be done, are there labs and other things. And so there's an agreement and it's written into this algorithm. Again, it allows for those frequent touch points with our patients or caregivers. So we're not relying on in-person visits and delayed availability to make these adjustment changes. The other benefit is nurses are great educators. So they're building these relationships and they're able to incorporate education and lifestyle modification. So it's a little bit of that education and not just the medication focus, but helping them to adapt to a healthier lifestyle which leads to long-term better outcomes. And of course we need these to be protocol based to really work us to nurses to the top of their scope. Again, we've talked about this time and time again is you've got to have that multidisciplinary team. Ensure you've got your physicians, your APPs, your nurses but also think about your administrative partners and pharmacy. Even if you don't have pharmacy on your cardiology team, can you pull them in and have them help you with this protocol? You want to align your orders and your protocols. So usually you've got to have both so that we're protecting both sides and making sure that we're following these steps completely and thoroughly. And then you want to think about your patient enrollment strategy. How are you going to identify these patients? Is it something that's identified at a clinic visit? Are you being more proactive and pulling a report out of Epic for this population? And then how are you going to communicate to that patient that we're going to enroll you into this clinic? And it's really about the communication and how it's presented. You are part of that team. You know, we hear time and time again, well, my patients want to see the physician. I understand that, but you work with the physician and you'll build that relationship with the patient and they will see the communication. So these models are very, very successful. They build trust between patients and providers and then between the care team itself. So they can be really beneficial and some positive outcomes. When you're thinking about these clinics, you really want to think of the different elements of how you want to address things. So in these protocols, you've got to think about, okay, what is my population? So let's think about maybe a hypertensive clinic. What medications are you going to include? Of course, you've got your typical ACER, calcium channel blockers. Do you want to add diuretics in there? Really honing in on what medications you want to pull into your protocol. What is the treatment plan? That needs to be clearly documented in the notes so that there's clear guidance. As Ginger mentioned, we don't want to bring, have these conversations with patients and then spend 40 minutes, an hour trying to track somebody down or a day even messaging. So we really want to make it clear what the treatment plan is. And that does include the patient's goal. What's their target blood pressure? Do they need labs? Are you incorporating, you know, chems, VMPs, you know, checking that renal function, make that part of the protocol. Don't forget your inclusion and exclusion criteria. You know, is this going to be focused on adults? Is it a specific population that's post-discharge? You know, the other side of that is who are you excluding? So you don't necessarily want to include patients that may be higher risk, like a high-risk pregnancy. Maybe they're being treated by renal and they're on dialysis. Is that something you want to include? Or maybe they're palliative or on homebound care and they're getting monitoring, so you don't want to duplicate those efforts. And then as we mentioned, don't forget the lifestyle modification interventions. Is there smoking cessation they need? Do they need sleep study? Nutritional counseling, behavioral health, those sorts of things can be incorporated in this to support the patient. And again, within those, within the guidelines, we want to make sure we are raising the bell of when they're outside of those parameters. So these are just things to consider as you're putting your protocols together. This is an example, and we are happy to share this. This is one specific to fluid overload, so weight gain. Again, you just really want to make sure your teams can address the specific factors that the patient is calling them with. So they need to be clear and simple. They don't have to be overwhelming or complex. So happy to share this. This is just an example, and we'll find a way to get this out. And really our outcomes, not only for our patients, but our care team members. As we hear time and time again, there's a shortage of nursing and we can't retain staff. We want to make sure it's an environment where they feel they have a purpose. So not only are our patients going to have better outcomes, they're getting high frequency touch points. So we're making adjustments more quickly so they can meet their goals in a timely fashion. They have access to a support person. They build that relationship and that trust. So of course they're going to stay more engaged and motivated and have better outcomes. Our care team members, our nurses, we need a purpose. We need to feel like we're part of a team. So it really, through establishing this trust and collaboration with our providers, really enhances our wellbeing and satisfaction. So that can lead to recruiting high quality nursing staff and retaining them because they know they are valued. So moving on to another kind of high-occurring role is stress testing or diagnostics. And this is generally not hospital outpatient department, but we see this very commonly, obviously, in cardiology. So according to the AHA supervision of exercise testing by non-physicians, we don't have to have physicians in the room. Obviously there's not the time for that, but the physician does provide oversight and they are responsible for the team members and administering the test. So a lot of organizations have used nurses, exercise physiologists, APPs to help administer this test. Again, really important that whoever is running it is exhibiting competency. This is not a easy thing. We need them to be alert and vigilant and they need to be aware of what they're looking for. So they must be competent. And the level of supervision is really based on that patient's level of risk. So whether that physician is in the room is gonna depend on the acuity of that patient. And we need the person, the nurse to be able to make that decision and communicate with the physician. Great thing is maybe checking the schedule at the beginning of a day and having a quick huddle to review patients and say, hey, this one needs to be, this one's got a history of VT. We really need you in the room. This one's a little iffy, maybe right around the corner. So having those conversations and the ability to have open communication is gonna be critical. And really it's about appropriate test protocol selection, appropriateness for the patient and interpreting the test in terms of, is this a normal cardiac response or is this something that's abnormal? And we really need to stop the test. So it's really about the test, the safety of the patient. So guiding principles for this role is making sure again that we're screening and identifying those high-risk patients. Are they high-risk CAD, history of ventricular arrhythmias, severe pulmonary artery hypertension? Those are the patients that they need to be on the lookout for. And not only being able to respond in an emergency situation but we need to make sure that you're running drills regularly. So the team needs to be aware of the emergency response plan but they need to practice it too and have some leadership skills to coordinate that. So that's something I like to look for as well in these candidates. And again, protocol-based, clear and defined, agreed upon and competencies. So core competencies for these, obviously they need to know anatomy and physiology of cardiopulmonary system. That way they know how the test is performed, what's happening, a typical response or what's not a typical response and how to intervene. So it's really important that they're experts in this area. And again, I emphasize the emergency response, not only BLS and ACLS but how they're responding to patients that maybe have ET. Being able to identify the dysrhythmia and how to intervene is gonna be crucial for this role. And don't forget the nurse is not really just doing things during the test but leading up and after. So your policy should really align with what that nurse is doing. So when we think about nursing care, again, can't stress the importance of the competency but we're working them within the scope under a physician order to make sure that patient is well-prepared in advance of the procedure, that they know what to expect, know what they may feel and what's normal or not normal. They will execute the ordered protocol. So they may be getting EKGs, operating some equipment, monitoring vital signs obviously, identifying cardiac rhythms. So the bulk of it is during monitoring but they also need to have the ability to communicate any changes in the status to the provider quickly and efficiently, clearly and be able to terminate the test if needed or implement those emergency measures. So again, this is a very common role but it takes a very experienced and skillful nurse to do this role. And I know we mentioned procedure planning. I wanna touch base on it a little bit because there's so much coordination that goes into play when we are getting a patient ready for a procedure. And I really wanna highlight the work that goes in before. And it's important that you're streamlining your processes and a lot of locations have a dedicated person to do this. And if not, that's okay. More of a case to streamline your processes, right? Making sure you have standard order sets, standardized patient instructions so they're getting consistent, reliable information. Are you using the same materials? Making sure that they're clear expectations and standardized pre-procedure testing. So it's really focusing on efficiency and throughput, decreasing those communication gaps because the one thing we don't want is the patient to not have all the information and maybe they come in for their H&P visit and they go home and it's, oh, we forgot to get your lab. So you gotta send them somewhere else potentially to delay care. And that's a burden on the patient. And it's also an opportunity to educate and move them to making an informed decision. So it's very important that these are aligned. We do have an example of some standing orders for common procedures. Again, happy to share, but this sets expectations and allows for some efficient workflows by that nurse. And then all of this is really important as we lead into the day of the procedure because what we don't want is the patient showing up unprepared, maybe they ate too late or we didn't do something and their case gets delayed or canceled. So it's really important. This is all tied up in a bow. So again, those patients can sign their informed consent and be comfortable with it, really have full awareness to it, proper med reconciliation. All of these things are really crucial to making sure that the patient receives their procedure on that day. And time and time again, we hear about delays and cancellations and we really wanna make sure that we're not inconveniencing patients and our care teams for that. The last role that I wanna talk about is our nurse navigators and coordinators. So these are really kind of on the forefront within cardiology. We're adapting these from oncology and they can be inpatient, but we can also use them outpatient or maybe it's one that spans the continuum. We see them mostly in heart failure and structural heart. So kind of two different areas, right? One's more disease focused, one's more procedure focused. We also see them in advanced heart failure, EP. We're seeing more and more in cardio OB and oncology as those programs are stood up. Some other types here very commonly about coordination referral management. So there's lots of ways that we can use them. There's still really no clear definition or differentiation between coordinator and navigators, but we did a survey this year and you can kind of see the themes for both. So I only put this up here to say, how is your organization naming them? What's kind of your standards and your requirements? And it's really more important than the name. It's really about what they're doing and how you define their roles and responsibilities. So we'll talk about that in just a moment. So these roles are crucial to support program growth. Programs are struggling with capacity. These are a way to help with that, help support growth, efficiency, and managing these high numbers of high acuity patients. So it's really about the right patient, the right care at the right time. Ensuring we're using predictable pathways and increased touch points. And it's purposeful standardization. So when we say that, it's the 80-20 rule. So you can anticipate about 80% of your patients falling into these predictable pathways. The 20-ish percent that doesn't, that's when you can escalate. So if you think about all the portal, the inbox messaging, the calls, the burden on providers, as opposed to getting 100% of those messages and calls, narrowing that down to around 20% is a significant relief there. And it can improve turnaround time and response time to our patients. So that's why this is really important. And we wanna make sure that, again, we're considering that patient panel. Who are you managing? Is it heart failure? Is it EP? Is it structural? Look at your data, look at your populations and hone in on them. Is it going to be focused more on pre and post procedure? So we think structural heart ablations for EP or VAD. Is it going to be more around hospital follow-up, maybe in the instance of heart failure? Is it gonna be that more referral management? What is your organization and your practice need? And I encourage you to keep these specialty focused. What happens is we tend to pull them into the clinical cardiology or general cardiology realm, and that really dilutes their effect and their benefit and the ability to show their usefulness. So sometimes it's hard and it's very tempting to pull them into other responsibilities, but I encourage you to keep them focused. One way to do that is really defining their job description. You wanna make sure you're writing the job description for what your program needs. So I know we all have those nurses that, oh, they'd be a great fit. I encourage you to make sure that you understand what your program needs first before you fill the position. So make sure you're meeting your program's needs. Pull in the team members, the stakeholders who's involved, level set and get on the same page to make sure that everybody has the same goals. That's how you're gonna define this role and keep it focused. So example of a job description for a nurse navigator, again, these have to be highly skilled team members. So you wanna make sure that they've got experience. Typically these nurses are bachelors or higher, MSNs or CNLs can be great candidates for this role because they have the additional education and skillset that are really beneficial in this role. Typically we see salaried positions, not hourly, generally Monday through Friday, and there is opportunity for flexibility here. So think about those blended positions of how much is in-person versus how much is remote and what are those opportunities there? So core responsibilities for this role really kind of fall into four buckets. Again, you've gotta look at your data and see where your priorities are. You need to be focused because if you have them try to tackle everything, again, they won't be as effective. So start prioritizing and see where they're gonna be most effective to your patient population. So transition of care, again, guiding through the care continuum, being a liaison for that person, the patient and their family. Clinical responsibilities is really things around that pre-procedure or disease management, scheduling appointments and test procedures. Are you utilizing them for remote device management? Thinking about heart failure space, maybe monitoring cardio memes, heart logic, things of that nature. There's huge opportunity there. And again, a lot of the lifestyle modification and medication management falls right into their bucket. These roles also have a lot of administrative tasks associated with them. So they do a lot of data collection, analysis and performance improvement work based off of that. That's really important that they're involved in these because they're the experts. They know what's happening. They can help facilitate effective, meaningful improvement work. I see a lot doing chart abstraction. Again, I kind of caution you there depending on volumes because chart abstraction can be a full-time job. Really, I would advocate that you're using your coordinators and your navigators to work off of your abstraction data and dashboard. So just my two cents on that. And then expert resource. Your navigator is the face of your program. They should be the person that the organization is turning to. So really equipping them to do their best and be a resource that your organization needs. And I'm sorry, I'm going through this fast for the sake of time. Just a couple of metrics here that are common. Again, we'll send this out. I do wanna say with readmissions and length of stay, it's very easy to say that once we get a navigator or coordinator, they're gonna impact that. Yes, but let's not put the full weight on their shoulders. Usually we see improvements because they're helping to coordinate communication and care in a timely manner. So that's your biggest win there. Successes for navigators. We've seen a lot of programs that do it well. They are really able to keep these positions filled with high satisfaction and low turnover. So you wanna make sure you're engaging with these nurses. They're highly valuable to programs across the country. And again, just a little bit more on the value proposition here. We all know the benefit, but making sure that they're part of your care team and not kind of working independently is gonna be crucial. I wanna jump into onboarding. And it's really important that we set our nurses up for success. So we've gotta build a foundation for them. So I encourage you to have an orientation framework, making sure they have a dedicated preceptor and that everything is intentional and clear. Keeping open communication and frequent touch points with your new employees and ongoing is a huge satisfier for team members. And then working in your competencies. So I recommend a 12-week onboarding program and you wanna look outside of what their role is. So you really wanna connect them with all aspects of your cardiology program so they're aware of the resources and processes. So if I am a nurse working triage and doing nurse closing, I wanna go see an inpatient cath one day. I wanna go to the heart failure clinic. I wanna round with the inpatient EP team. I need to follow a nurse or a APP ginger and see how she's rooming. Get them exposure early in their onboarding process. And then start them on competencies. So you wanna make sure you have very clear initial competencies and you're doing that on a ongoing basis. And this will help with recruitment and retention. Providing and investing in your nurses with ongoing education is gonna really be a huge satisfier. Giving them that sense of purpose and drive, allowing personal and professional growth and making it part of the culture is going to be a huge satisfier for nurses. And generally that will help us keep us working with you. These aspects of culture and your investment in our development will help to stay. So realizing the constraints that many organizations have in terms of educational resources, I'm proud to announce we just launched Cardiovascular Nursing Essentials. This is a program that will go over very basic foundations of cardiology and then dive into very specific disease center care models. It's heavily based on decision-making, ambulatory nurses and their ability to function at the highest scope of their license. And really to help them grow in their role within cardiology. This is a 12-week module. It does include those orientation and competency and lots of great resources. So please, if you have an interest in this, let us know. We do have a lot of brand new Academy offerings and I know we're at time, but I do wanna remind everybody that you do get one free Academy course with your membership. So any of these interest you, please take a look. We also are running a exciting special through the end of the year. You can get $100 off any Academy course by entering Academy 100 and you can use that on multiple courses. One other note, you can buy in bulk and use those as you go. So please let us know if you have questions. Ginger and I are here and I'm sorry, I ran us right to the end. So I'm not sure if we have any questions. We just, we had a couple, I answered them in the chat and then we have one related to some examples of protocol standing orders. And well, there's a fair amount in the Academy course as far as some competencies and things like that. But we have a few that we can, we'll kind of put together a few documents that we'll share with all of our attendees today. So we'll do that as part of the followup. And I'll just do a quick plug. Jenny has been amazing. We're so happy to have her on our team. I have watched and have seen the content that she put together for that nursing essentials course and it is top, top notch. In addition, I'm a huge advocate for education but I want you to think of it as more than education. What it really is is standard learning. So it creates an environment where when you either bring people in or transitioning roles, you're giving them all a fair playing field, right? We, I can't tell you how many times that I go into places to do consulting work. And when I meet with the team members and I interview them, the feedback I get is I didn't get much of an orientation. I kind of got thrown in. I'm a self-driven person so I figured it out or I struggled and I still struggle. And it's, and now I'm getting bad feedback but I feel like I didn't get what I needed to do my job. And a course like this gives people what they need to do their job. Now they need additional things but it gives you as an administrator and as a leader, you know the level of education or the level of information that they've been exposed to and that you have provided them. And that creates some liability safety for you because you know, if there's ever a problem, we provided he or him this education and then it also creates an environment for engagement because you care about my professional development and you're giving me the tools and resources I need to do my job. And also I would just say, frankly, it's an enjoyable process. Jenny is an amazing teacher. So that's the plug, but we did this based on your needs. So the big piece that we heard last year is we need help stabilizing our workforce. There's multiple levers you got to kind of pull to really get the stabilization that you're all looking for but a key one is the standard learning. So does a nurse have to be a MedEx team member to take the course? Nope. How long is each weekly module? Jenny, I'll let you answer that one. Yeah, so it varies. I would allow for one to two hours. There is assigned reading and then we'll do, there's a recorded PowerPoint with it. So to kind of hit more of the real life implications. So they're getting the didactic kind of book learning but then the recordings are really, how do we implement that into real life care? And I wanna say when I was creating this, it was such a joy because I look at it through the lens of when I transitioned from working a CCU job in the hospital to transitioning to the outpatient side. And there was a lot I didn't know. And also there's that transition of, how do I take having a patient in front of me and controlling all these things to transitioning to an outpatient setting where I'm interacting in a much different way where I can't see or touch my patients. So it all came from the lens of, I wish I'd had this when I made this transition. So a year, a year, one to two hours. Some content is more in depth than others, but again, didactic book with real life implication and application. And I believe that there's CEUs associated. There's about, I think it's 22. So it's a good number of CEUs and they can take it at whatever pace they want. It's open for a year, I believe, once you start. So you don't have to keep to that strict timeline but that's how it was laid out as an overall 12 week module that aligns with a 12 week education orientation plan. Perfect. Well, thank you everyone for joining. We appreciate it. Such an important role. You have our emails, reach out. We'll get you, you've got the presentation. We'll get you some followup documents and let us know if you have questions and enjoy the rest of your day. Thanks for joining us. Thank you guys. Sunny.

cardiovascular nurses

triage

team nursing

nurse visits

nursing coordination

workforce stabilization

roles and licenses of nurses

staffing ratios

protocols and guidelines

patient care