Transcript: Chronic Care Visits for New Nurse Practitioners

Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

In this week's episode, I want to talk to you about chronic care visits. I know these types of visits can be really overwhelming, so I want to talk about the general way that I approach my chronic care visits and how to do it in a timely and organized way so that it's not hours and hours long and it's also done in the safest way possible. I also have some quick tips and little pearls of practice to share in there, as I usually do.

Before I jump in, I just want to share that I'm really excited. I'm working on a brand new course to help with chronic care management in primary care, specifically with adults, so the management of diabetes and medication, hypertension and hypertension medications, as well as a component of chronic kidney disease, so the assessment of CKD, diagnosis, monitoring, things like that, when to refer, all that good stuff. That's a brand new course coming this fall, so if you want to join us for that, it's at realworldnp.com/courses. I have a feeling the first version is going to be live with yours truly, so if you would like to attend that or if you're interested for more details and you're not quite sure yet, still get on that wait list because you'll be the first one to find out. However, let's get back into this episode.

When it comes to chronic care visits, these are super common in primary care. It's usually a chronic care visit followed by an acute care visit, acute care meaning not hospital care, but something urgent, like an urgent care type of visit, sick complaint, et cetera. But the vast majority of primary care is chronic care management. The top three conditions are diabetes, hypertension and CKD, and they're all tied together. I want to walk you through how I conduct these visits and hopefully this will help keep you from feeling overwhelmed and feeling more confident with how to conduct these in a safe way.

Step number one that I always do is medication reconciliation, or I always endeavor to do, I am not perfect, this is the real world here. I try to start with medication reconciliation, especially if it's someone that I've never met before. This is incredibly common in primary care with new grads because everyone's new to them. There's a couple ways to do that and I have a couple little hacks there. Number one, you can ask the patient, of course. The other is hopefully you can involve your staff that work with you in a systematic way, where your medical assistant or whoever it is that's rooming your patient will also ask about medications and start that reconciliation process for you. Again, it's your license, so you have to verify if it's somebody who doesn't have a license that you do, if it's a nurse it's different, but they can start that process. Hopefully, the other thing is that the patients have a medication list with them maybe in their wallet or something like that, but if they don't, hold that thought.

The other one, the really beautiful pearl of practice that I got recently working with, or sorry, excuse me, doing an interview with a pharmacist is collaborating with your local pharmacist. This is easier. If you haven't watched that already, definitely go back and watch that, it's wonderful. But the main thing about that, in terms to collaborating with pharmacists, this is easier done in a community health center setting that has a community pharmacy associated with it versus the larger commercial pharmacies. However, one of the things that she said that she loves about being a pharmacist is that she's a hub for the patient. Many medication issues come from specialists, various specialists as well as the primary care prescribing the same medications, making changes and not fully communicating with each other, whereas the pharmacist is the front line for that and that collaboration and that communication and all that stuff. That's the first thing. Medication reconciliation is just a safety thing and it also helps you very quickly get the status of the chronic conditions in front of you, especially if you've never met them before.

That brings me to my next step. Step one is medication reconciliation, hopefully with the aid of your medical assistant or nurse or whoever rooms the patient for you, the next one is just, regardless of the chronic condition in front of you, whether it's a rheumatologic condition, diabetes, hypertension, CKD, et cetera, et cetera, whatever the chronic condition is, asthma, COPD, what are the signs that it is stable, worsening or improving? What is the status here? Again, that quickly ties you from the medications and depending on how many they're on and the doses, what's the status, where are we, let's orient ourselves. Are we stable? Is this patient getting worse? Are they improving?

Then, generally speaking, this takes some learning and some studying, but just knowing, how would you know, what are the questions you would ask to determine if they're stable, worse, or better. Again, this builds with time and with knowledge and even just muscle memory, because I know it feels like we don't have enough time, especially as a new grad when your brain hurts at the end of the day and you feel like you have absolutely no time to just do anything. This can also come with muscle memory, when you start doing the same things over and over again. I have to say, if you've been following me for a while, you know that I do things in a systematic way, as much as I can, because it reduces that mental load when I do the same things in the exact same order every single time. That works for me, that might not work for you, but that's a muscle memory thing. Again, how would you know this chronic condition in front of you is stable, worsening or improving, and then can you ask them how they're feeling, symptom-wise.

Which brings me to my third point, which is about red flags. What is the absolute worst case scenario for the chronic condition sitting in front of you? I should have started with this context of usually the situation is a new nurse practitioner. I work with a lot of new grads and this comes up a lot, where they're seeing the patient for the very first time, they're, for example, an 83-year-old patient that has multiple chronic conditions and a very long medication list. That type of scenario can feel very overwhelming, even for experienced providers. This method that I'm describing is a way to really anchor yourself and make sure you're not missing anything and that you're giving the safest care, especially in the face of so much to assess. These are the get to the heart of it, bare minimum safe care elements that you can incorporate into your practice.

Again, just recapping. Number one is medication reconciliation. Even if you don't know what meds this person should be on for their polymyalgia rheumatica or whatever their chronic condition is, what meds are they currently on, let's just start there. Collaborating with our pharmacist if we can, they're wonderful resources for us. What are the signs that it would be stable, worsening or improving, and can you learn that if you don't know? The third thing is red flags, that's kind of tied into there too. What is the worst case scenario for this chronic condition sitting in front of you? Then hopefully you have the knowledge of at least hypertension, diabetes, and then as you expand your knowledge further you can into those chronic rheumatologic conditions or other chronic conditions you are less intimately familiar with.

But just as a practice, before you even see those patients, especially if you're a nurse practitioner student, what is the worst case scenario with hypertension, for example? Hypertensive emergency. What are the signs and symptoms that you would know that you were in that state? Do they have chest pain, vision changes, shortness of breath, the worst headache of their life, blood pressure of 200 over 100? Are they there or are they not? How close are we getting there? I talked a little bit about this in the other hypertension video that I made, I can link to you down below this.

The next piece is, do they see a specialist? That's just one quick question. This is kind of like the triage-based, easy check, check, check, check, check, for all the chronic conditions. Do they see a specialist and when was the last time that they saw them? Just even asking that question, putting that updated info in there, you've covered your bases. They saw them last week, no new orders, everything is the same, medications are the same. Perfect, boom. You've assessed that chronic condition, at least the bare minimum safety.

I have a quick tip to throw in here, is that I love the use of quick texts, especially when I was a new grad, because it would help cue me in the history of present illness section of what I should ask for each of those, .hdn, .dm. I just made all of those and so it told me what questions that I needed to ask so I didn't have to rely on my memory to make sure I didn't miss urine micro albumin, monofilament tests, et cetera, et cetera. Spoiler alert, or fun fact, either one, inside of the chronic care course, there's going to be quick texts available for you, the ones that I use that you can download, or you can make your own.

Then the other quick tip is that you can copy and paste your last HPI if you've seen them before, because you wrote it. You have to update it of course, but that's another quick way to recap. I think once you'll find, especially if you're a newer clinician, it can feel super overwhelming to have that patient in front of you with multiple comorbid conditions, multiple medications, but you'll get the hang of this, where it's like, "Oh, actually you're here for your check in visit. Now I know all of these things, I know the status of your regular status of all these chronic conditions and it's all the same." It's not always that beautiful, it's not always that easy, but this approach is to get a step-by-step of how do I orient myself, how do I quickly get to the heart of the safest option for this patient and take it from there.

Just as a recap, number one is medication reconciliation, number two, what are the signs or symptoms that it would be stable, worsening or improving, tied into that are what are those red flags, can you assess for red flags, just straight up assessing for red flags. If you ask nothing else, what are the worst case scenario questions to ask about this chronic condition in front of you today? Next one is do they see a specialist and when was the last time they saw them, and that gives you further confidence about, okay, this is probably a stable condition then. Then, again, using those quick texts and copy-and-paste tips of your own previous note.

Then the last thing I want to wrap up with is that when to come back, when do we have patients follow up with those chronic care visits. This really depends on the situation, which is a not that helpful answer, but really, generally speaking, for stable chronic conditions, it's about every three to six months. It's condition-dependent, but it's about every three to six months. However, if there's something that needs to come back sooner, somebody needs to come back sooner, that's up to your discretion. If it's something that's worsened or you've made some changes, maybe you bring them back in a month. If it's really severely declining or worsening in status of that chronic condition, it's an exacerbation of some kind, again, individualized basis, but that could be a couple of days to a week or two weeks.

That's it, that's my general approach to my chronic care visits. Again, if you want to join us or find out more information about the chronic conditions course that is brand new this fall/winter, it's at realworldnp.com/courses. Thank you so much for watching, hang in there, and I'll see you soon.