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AANP Member Spotlight: Nurse Practitioners (NPs) Providing Operational Leadership During the COVID-19 Pandemic

Headshots of Shelly de Peralta and Yichun Michelle Fang
Shelly de Peralta, DNP, RN, ACNP-BC, and Yichun Michelle Fang, DNP-C, RN, FNP-BC

Hear from Shelly de Peralta, DNP, RN, ACNP-BC, and Yichun Michelle Fang, DNP-C, RN, FNP-BC, on how they redesigned the workflow in the VA Greater Los Angeles Healthcare System to add virtual care visits as a primary means of care in the cardiology division.

Q: How has the COVID-19 pandemic and state of emergency affected your work and the VA Greater Los Angeles Healthcare System in general?

Dr. de Peralta: The U.S. Department of Veterans Affairs (VA) is a leader in virtual care and has provided it for decades now. Recently, it was introduced to specialty areas, so we were already familiar with and had training on VA Video Connect, our secure virtual care platform where patients and their providers can interact. In response to Los Angeles’ Safer at Home order and the statewide emergency, we had to transition from face-to-face (F2F) visits to virtual care extremely quickly. For the cardiology division alone, this involved 53 clinics, 28 fellows, 16 cardiologists, four NPs, numerous allied health professionals and 9,900 unique patients.

After the national emergency was declared, our chief of cardiology also had an emergency staff meeting to discuss how to transition to 100% virtual care, acknowledging we had never done this before and were not ready with adequate systems in place yet. Everyone, all disciplines and all employees, showed flexibility so that necessary changes were implemented very quickly.

Ms. Fang: This really forced us all to rethink how we can do our jobs safely while maintaining the standard of care and patient safety. Initially, there was an increase in taking care of patients and figuring out this new process simultaneously. Collaboration was integral to our systems redesign.

Q: What challenges were you facing initially in transitioning to a virtual care model? What strategies did you use to overcome those challenges?

Dr. de Peralta: A physician colleague and I took the lead on cardiology clinical operations. A workgroup was formulated to spearhead coordination and transitioning patients to virtual care, and we were lucky to have Michelle Fang get involved. Together, we worked with the telehealth director and another physician interested in telehealth to strategize our implementation. We knew we needed stakeholder input, so we met with each subspecialty director to set up a preliminary process. For the first one and a half weeks, everyone was trying to do the best they could, but we couldn’t get a handle on the process of standardizing the approach concerning the best timing to call patients, documenting their consent to switch to virtual care, determining what means of communication they preferred, identifying how to notify the rest of our colleagues regarding when they can call patients, assigning virtual attendings to oversee care provided by trainees and more.

Each clinic had varying degrees of success in obtaining a virtual care visit, but we needed to ensure our success rate was 100%. We met to discuss quick, rapid-cycle process improvements to get us where we needed to be: We needed support for all services, and support for all patients, without clinic cancellations. That said, it’s one thing to handle your established patients during a crisis, but it’s another to handle an increase in new patients. I knew the NPs I work with are a great deal of support for me and were an untapped resource. How could we get them involved? My NP colleagues and I met and subdivided the workload. Each NP willingly assumed responsibility for a given subspecialty to provide guidance.

Ms. Fang: The majority of our patient population is on the elderly side. Challenges we faced included issues with the patient’s level of comfort with technology and their access to technology such as email, smartphones and Wi-Fi or data. As telehealth and virtual care was something we were still rolling out, our providers also had varying levels of comfort using the technology. In addition to VA Video Connect, we also had telephone as an option — having two modalities allowed us to reach more patients.

Dr. de Peralta: This was a 180-degree change in operations for us as we determined how to best approach the virtual care recommendations with our patients. More so than ever, we needed increased cooperation and collaboration. It was also time intensive. We did not know what we needed to do, how we needed to do it and how to get started. This was a new way to approach care for 100% of our patients. One challenge we faced was patients’ hesitation to accept virtual care and how to approach the topic with patients when we didn’t have an established relationship. The Safer at Home order actually allowed the transition to be much easier as patients began to understand the importance of staying home. In addition, as we were working on the transition, we noted variations in the approaches between cardiology subspecialists when addressing and explaining virtual care to patients. The first order of business was to have a unified approach using an approved script that incorporated the words “safety” and “emergency.” We quickly formulated a script that was to be used during patient conversations, which provided a uniform platform in assisting with the transition.

Ms. Fang: Having the standardized script and standardized flow diagram allowed the cardiology division to have a cohesive response to the pandemic, cutting down on confusion and mixed messages. It also helped us to take stock of our human resources, repurpose them and develop creative solutions to ensure everyone had access to the technology we needed to use.

Q: Can you share an example of how staff use this workflow diagram to help patients with different needs?

Dr. de Peralta: The Provision of Virtual Care to Cardiology Patients Amid National Coronavirus (COVID-19) Emergency flow diagram began as a Microsoft Excel worksheet that mapped out all clinics, days, frequency and hours of their occurrences. The hidden resource was our NP colleagues; as noted before, they all stepped up and assumed responsibility for a given subspecialty area. The workgroup provided ongoing guidance to our NP colleagues. Our flow diagram at this point became a roadmap to virtual care.

NPs triage all patients scheduled for the following week in all of the clinics, which are divided by their assigned subspecialty. Patient care is reviewed and triaged for stability and suitability for provision of virtual care. Clerical staff call the list of triaged patients, using an approved and standardized script, to offer virtual care. If a patient insists on a F2F visit, the subspecialty attending physician calls the patient to further discuss their needs. Clerical staff then document the patient’s preferences on the schedule. The list of patients is sent to each of the fellows, along with their assigned virtual attending cardiologist. New patient consultations are managed by NPs directly, and they’re also called in to inquire about the status of and patient’s interest in virtual care. Often, patient consultation questions can be addressed during the NP’s initial phone call. All new patients are staffed by a cardiologist assigned as consult attending. Patients are contacted by their assigned provider any time before the date of their scheduled appointment. A progress note is written documenting interaction. All requests for new consultations are assigned an attending cardiologist who hosts virtual clinics and manages patients via telephone or video call. During the virtual call, any patient who requires an in-person visit is switched over to be seen, as appropriate, for a F2F visit.

Q: What results have you seen with this new workflow in place?

Dr. de Peralta: In the first week, 71% of patients transitioned to virtual care. By week two, it was 92%, and by week three, it was 98%. Week over week, these results reveal our success rate at protecting patients. We’re keeping patients off the roads and away from crowds. Our fellows, residents and interns are largely being transitioned to inpatient service away from the specialty clinics, so it’s very important that we keep critical health care providers safe. When we use this flow diagram as our roadmap, we’re also helping the trainees stay home and stay safe. They don’t have to physically come to the clinic to see patients. They can call on weekends when patients are home.

We’re also more efficient using virtual care. Internal consultations for conditions such as arrhythmia are now managed via electronic consultations assigned to electrophysiologists who are working remotely from their offices. In addition, our no-show rates have decreased to 3%.

Q: What are some of the key takeaways you’ve learned? Will your experience moving to virtual care influence the delivery of care in the future at the VA?

Ms. Fang: Having the flow diagram simplifies our process; it is an easy reference and provides uniformity in approaching patients for telehealth services going forward. The VA Greater Los Angeles Healthcare System is just one medical facility covering a large area — we see patients as far north as Santa Barbara and Bakersfield, which is a significant distance to travel for many. Telehealth provides another option for patients to access health care if they are not physically present. We’ve had to stratify risks related to the clinical indication for non-urgent diagnostic studies, and telehealth and virtual care has provided us with the platform to assess patients by gathering a history, evaluating visual cues and having direct patient interaction. Telehealth and virtual care are here to stay.

Dr. de Peralta: I personally felt that I was responsible for the success of our transition, like this project was resting on my shoulders — but I realized it didn’t have to be. One of my key takeaways was the importance of using everyone’s capabilities during a crisis. In addition, we’ve seen that we don’t need F2F visits for many cardiac consultations. It’s allowed us to pause and reevaluate the frequency of seeing patients every three-month or six-month interval. Appointments now may be changed to every six months with a virtual care consultation call in between for reassurance. Patients love that we’re spending more time speaking with them and hearing their concerns.

Now, insurance providers need to examine discrepancies in reimbursement rates to help steer everyone in the right direction. NPs are also on the front lines during the COVID-19 pandemic, so we need equal reimbursement for physicians and NPs. Patients are grateful for the care they’re receiving, and they understand that we’re trying to avoid exposing them to the virus. Many patients are now concerned for us, saying, “We need you guys! We need NPs!”

Q: What advice do you have for other NPs looking to create a similar process in their practice?

Ms. Fang: It’s incredibly important to identify and get your stakeholders on board. We worked with the director of each subspecialty to understand what they needed, what resources were available, what equipment was needed and how we could help each director meet the overall transition goals. It was also important for us to reach a consensus on how to handle patients for telehealth. With one message, there is less confusion. Once we made it a process-based transition, we had clear roles and responsibilities for each individual, which removed redundancies and ensured that, if a provider or staff member were to get sick, we would know how to prevent any lapses in care or communication with patients.

Dr. de Peralta: It’s also important to take a broad look at your processes and walk through each process yourself to find areas to increase efficiency and quality of care. Don’t be afraid to make systems-level changes. These are unprecedented times.

Q: What makes NPs, specifically, well-suited to be on the front lines, create new processes like the one you’ve created and to improve the delivery of care?

Ms. Fang: As NPs, we can bring a unique perspective. We’ve always had close relationships with our physician colleagues, nurses and support staff. We value each person’s contribution and rely on collaboration and communication to develop new processes that are suitable for the division.

Dr. de Peralta: As an NP, it’s natural to bridge the gap between the nursing role and the provider-of-care role. Nurses are very operational in nature, and we are trained to learn and be flexible to fill in wherever there may be a gap in care. As NPs, particularly those with a doctorate in nursing practice (DNP), we are trained to fix processes to make them run smoothly. We have broad-based knowledge of clinical care and operations, but we’re also able to hover above it to outline the process, identify deficiencies or issues and map out an improved process flow. We value frequent collaboration, communication and reliability. At the same time, we are amenable to doing everything our colleagues do — from stuffing envelopes to making patient appointments — during this pandemic.

View the Workflow Diagram