A System-wide Vision for Primary Care

In 2014, the Primary Care Consortium (PCC) was created to enhance primary care across Emory Healthcare (EHC) and in the schools of medicine and nursing. Pockets of primary care already abounded, in both the clinical and educational arenas. What both areas lacked was leadership and an organizational structure to ensure that all players knew each other and could jointly plan, build, and implement processes to integrate and strengthen their programs and efforts.

Almost immediately, the PCC had a powerful impact on nursing.

Carolyn Clevenger 02MSN DNP FAANP, associate dean for clinical and community partnerships and a leader on the team that created the PCC, says its biggest impact on the School of Nursing has been creation of a pipeline to place advanced practice and baccalaureate students within Emory sites for their clinical preceptorships—especially in the highly competitive primary care slots. In the past, most nursing students went outside Emory for this final part of their training. Not surprisingly, many ended up working at the institutions where they trained, causing Emory to lose many of its best and brightest nursing graduates.

Today, a dedicated placement coordinator, equally funded by both schools and EHC, now oversees clinical rotations for all nurse practitioner (NP) and physician assistant (PA) students. Emory’s clinical entities request NP and PA students through a central office, which makes the match, giving first priority to Emory students. Another new jointly funded position is dedicated to the placement of RN students in ambulatory care rotations.

The concept is working. A year before placement coordination began, the School of Nursing placed 30 students at Emory clinical sites. Last year, it placed approximately 225 students. As word spread about Emory training and career opportunities, student enrollment grew markedly. From 2014 to 2017, BSN enrollment grew from 320 to 443 students, and MSN enrollment grew from 178 to 321 students. Last year, several new MSN graduates stayed on as part of Emory’s health care team.

The expanded involvement of nurses also is changing nursing’s place in EHC, says Deena Gilland 18DNP 07MSN RN, vice president and chief nursing officer for ambulatory care services (including primary care) and another nurse planner behind the PCC.

Nationally, more than 85 percent of advanced practice nurses today have been trained in primary care, but the roles they play on the health care team vary widely from site to site. To help address this disparity, Emory developed and implemented guidelines enabling nurses to practice to a fuller scope of their abilities, training, and licensure.

A second step was to create positions for nursing leaders at the front lines of each Emory clinical site. Nurse managers now oversee nursing teams at primary care sites. These leaders, Gilland notes, serve as triad partners with physician and administrative leaders.

This past year, another nursing role was developed, mainly for primary care clinics. So far, EHC has hired nine RN care coordinators who are imbedded in several primary care clinics to monitor and close any gaps in care.

Giving nursing more responsibilities, Gilland says, “has improved access to care, provided greater ability to touch patients in more robust ways, and resulted in better patient outcomes.”

Another bonus: Increasing the recruitment, retention, and advancement of EHC clinical nurses by inviting them to serve as student preceptors. More than 70 EHC nurses have gone through continuing education “boot camps” to prepare them to work with students. Participation has become part of EHC’s Professional Lattice of Advancement Plan to enable nurses to advance professionally while remaining at clinical sites.

Looking ahead, the PCC team sees endless opportunities to optimize nurses’ roles to meet growing demand in primary care. Plans include more NP-led clinics like the Integrated Memory Care Clinic (IMCC) started three years ago by Clevenger and colleague Janet Cellar DNP. Like the IMCC, other clinics in heart failure and diabetes provide high-quality continuity of care and provide easier access to care for patients.

The School of Nursing also expanded its curriculum in ambulatory care, including primary care. While many students who go through the course ultimately may work in hospitals and other acute care centers, they will come to think more broadly about the continuum of care, from pre-admission to discharge and follow-up, and how to influence that care as nurses.

Carolyn Clevenger, Ted Johnson, and Deena Gilland meet at a local restaurant to compare notes and ideas about health care practice.

Creating the ‘Geneva’ of Primary Care

The Primary Care Consortium (PCC) is a success story that grew out of strategic planning by Emory Healthcare (EHC) and by Emory School of Medicine in primary care.

The timing was right, says Ted Johnson MD MPH, chair of family and preventive medicine in the medical school and program director for EHC primary care. Demand for primary care was growing nationwide in response to health care reform, a new emphasis on ambulatory care, an aging population, and the need to increase effectiveness of care and decrease costs.

As part of its goal to touch 1 million patient lives every year, EHC was opening new primary care clinics and hiring more primary care doctors. But EHC and medical school leaders, including Johnson, knew that even with more primary care doctors coming on board, physicians alone could not handle the expected growth in primary care and population health.

Johnson, Carolyn Clevenger, Deena Gilland, and others designed the PCC as what Clevenger describes as an interdisciplinary thought-and-action tank involving equal partners. Johnson remembers when primary care was not a big priority for tertiary care/research-oriented academic health centers like Emory and when some physicians were not always eager to see nurses take on bigger roles in patient management and planning. He likens the PCC to Geneva, the Swiss city of diplomacy, “where people come together from different professions, backgrounds, and loyalties, to talk openly, resolve differences, and make collective decisions.”

Tania Solomon and Jan Johnson at Emory Clinic

A new NP begins to practice, grounded in primary care

After another day of spreadsheets and meetings, supply chain analyst Jan Johnson often went home feeling as if he should be doing something else—but what?

He always noticed the professionalism of Kelly Caulley 99MSN, his nurse practitioner at an Atlanta-area family medicine practice, and the time and care she took to really listen to him. When he mentioned his lack of fulfillment, she suggested he consider nursing. A light bulb went off, leading Johnson to enroll as a second-degree student in Emory’s Accelerated BSN/MSN program.

While Caulley inspired Johnson to become a nurse, his first preceptor, another Emory graduate, gave him the confidence to succeed. During his clinical rotation in Kennesaw State University’s student health services, NP Jade Lam 12MSN “loved sharing her knowledge and helping students develop and thrive,” he says. As Johnson moved through rotations in pediatrics, dermatology, primary care, and orthopaedics, he found that all of his Emory-trained preceptors had a true passion for teaching.

He quickly grasped what faculty and nurse clinicians taught him. “As NPs,” he says, “our goal is to address the presenting illness or issue and understand related health or social issues, such as how patients and families are coping.”

His student health rotations at Kennesaw and Emory’s Oxford College taught him the importance of developing trust and building relationships. Students often came in with one issue but responded to Johnson’s empathy and patience by confessing their real concern. He loved explaining how they could make better choices about their health and seeing them “get” what he was saying.

In June, Johnson 15N 17MSN began working in urology at Emory Clinic. Because of his training, he already understands much about Emory Healthcare’s culture and systems. He also believes his supervisor, Tania Solomon PA, and team members have confidence in him, knowing he is an Emory graduate.

“It’s a win-win,” he says. But the biggest winners, say his teachers and preceptors, are the patients who benefit from the broad primary care perspective the new NP brings to his work every day.