SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities. I'm Sarah Hexem Hubbard with the Pennsylvania Nursing Workforce Coalition and the Executive Director of the National Nurse-Led Care Consortium.
On this episode, we're going to have a conversation about the latest trends in primary care with Chanel Hart. Chanel is the Director of Nursing for PHMC Health in Philadelphia, where she oversees clinical nursing care at the organization's community health centers and shelter and respite services for people experiencing homelessness.
As a registered nurse, Chanel worked previously across various hospital settings and taught community health nursing. Recently, she earned an MBA and serves as the board chair for the National Nurse-Led Care Consortium, as well as the Vice President of the Philadelphia chapter for the Chi Eta Phi sorority, which is the first black nursing sorority in the United States.
And finally, Chanel is a board member of the Nursing Foundation of Pennsylvania, as well as a member of the American Academy of Ambulatory Care Nurses and the American College of Healthcare Executives. Chanel, welcome to At the Core of Care.
CHANEL: Thank you so much for having me.
SARAH: Chanel, you're among some of the most passionate nurses I know, and I know a lot of very passionate nurses.
But I actually did not know that nursing is your second career. I'd love to hear the story. How did you decide to become a nurse?
CHANEL: Okay, well, I've always worked in nonprofit. My very first job out of high school was working for Elizabeth Blackwell Health Center for Women. From there I went to the Youth Empowerment Services. So, within Youth Empowerment Services, we applied for a grant from the Beacon Schools, in New York.
So this was a 3 million grant to bring programming, after-school, and summertime programs to the children in some of the communities throughout the city of Philadelphia. So my grant was actually for Sayre Middle School.
So I thought if I ever left nonprofit, I would go into nursing. After I left, I went to EMS school at Jefferson and became an EMT to see if I even liked patient care. And from there, I went on to become a nurse. My manager at the time, who is no longer with us, pushed for me to apply to Dixon School of Nursing.
And I think she was more excited about me getting in than I was.
SARAH: And here you are today. So joining us at PHMC in 2022 as the Director of Nursing. And at that time, COVID-19 was very present in all of our lives and certainly through the clinical care here at PHMC.
CHANEL: So before I came to PHMC, I was at Jefferson Family and Community Medicine. So, we were kind of like in the heart of what was going on as far as COVID goes, because I facilitated a site on Jefferson's campus for people to come in to get vaccinated. At the time, they were calling the nurses back into the hospital. So if you left critical care, you had to go back in.
I did two, three weeks in the neuro ICU. So it was definitely a time. It was like being truly in a battlefield, at that point. And I remember the doctors, I remember the residents being afraid to address these issues. And who was it? Of course, it's us, the nurses leading the charge.
I remember a time I had two attending doctors and a student and they didn't want to go in to speak to an elderly patient that came in with respiratory symptoms. And I was so frustrated by the whole thing. I just kind of like put my mask on and went in the room and spoke to the patient.
And as I'm talking to her, I asked her which one of your grandchildren has the runny nose and she started laughing and said, Oh, two of them. I had to babysit while they were sick and she did not have COVID. Thank goodness. She had a basic cold from two of her grandchildren that are in daycare. But that kind of set the tone, I think, bringing nurses back up to the forefront.
And I was very glad to be a part of that. And seeing all of it just gave me a whole different outlook on the role of nursing and ambulatory medicine.
The outlook for nurses in the ambulatory care setting is definitely changing and the idea of them working at the top of their licensure is going to be vital.
SARAH: So now that you've been here at PHMC, I know that you've been part of a lot of different initiatives that have rolled out. One of the more successful initiatives, and certainly, on the radar, even nationally, you know, looking at, how we are engaging patients through digital tools, you helped design a blood pressure initiative, right? Can you tell us about how that project worked and the role of nurses how that rolled out and what success looked like?
CHANEL: When I came on board, the American Heart Association had a blood pressure program that they were initially just starting. But the person that was here before me was the one that took the charge. And once they left, I kind of picked up to see where we needed to work with this program. So the grant was in partnership with Bank of America for a $25,000 grant that we got to improve blood pressure with some of our patients.
So working very closely with the American Heart Association, utilizing tools that I found off their website, I was able to create an algorithm that allowed the nurses to lead the charge in reference to new patients diagnosed with hypertension.
So, essentially the patient comes in, they're diagnosed with hypertension. That generally takes three office visits. No one's ever, the very first time, oh, you have high blood pressure. Go be on medicine. But once the patient is officially diagnosed, the providers give a warm handoff to the nurses to let them know. Once the nurse gets involved, we can now schedule more visits with the patient versus them seeing the provider.
So the tool has everything from identifying the blood pressure, the social determinants of health, going over medication reconciliation, understanding where we're trying to get the patient to. And utilizing the monies that we got from the American Heart Association, we purchased Bluetooth-compatible blood pressure cuffs so that the patient can actually hook it up to their phone.
Of course, theres challenges when you have populations that are unhoused and at any time their phone numbers can change. So they have a paper tool that they can log in. Then they come to see the nurse. It could be every two weeks until we get the blood pressure where it needs to be. Once that happens, then we see them monthly and we record their success. A copy of the algorithm is put into the Epic system, that’s our EMRS system, to allow for us, when we're documenting, where we're reporting the metrics, that we can actually go right into EPIC and pull the numbers that we need. Because it is identified as self-measuring blood pressure RN note, so that, you know, it's easy to find. That's the most important part with documentation and data, making it easy to find.
We've been very successful and I'm very proud of the nurses at the sites where they reach silver status with the American Heart Association. So it comes in three tiers, of course, bronze, silver, and gold. So reaching that milestone of silver, especially on our first try at that, I'm very proud of them
SARAH: What did you hear from patients who participated in the program? What did the patients have to say?
CHANEL: The feedback that I got from the nurses is that the patients appreciate having access to care. And that's how they looked at it, having access. If there were questions about why their blood pressure kept rising that they could not fix, then they had someone that they could go to and it didn't necessarily have to be their doctor.
The patients do come back and that's the most important part. That becomes a huge bottleneck in trying to add any of these systems into place is getting the patient to actually come back to the office. So our no show rate actually is reduced when the patient is coming in to see the nurse versus the provider.
SARAH: Do you have additional thoughts on why folks are coming back to check with their nurse? Like what do you think's behind that?
CHANEL: I would like to wear this banner that say, cause nurses are just so amazing. But, realistically, I think that it is the amount of time that the nurse can actually give to the patient and the patient does not feel rushed. One thought that I've gotten from patients is they feel heard.
So even if I'm at the site and there's an issue or a discrepancy, when I intervene and introduce myself as the Director of Nursing, they are telling every single thing that they could possibly think. They appreciate their MAs, they appreciate their nurses. They speak highly of the nurses. Because the biggest part is that it's the time allotted for listening.
So we just have to take those couple of extra minutes to actively listen to what our patients are saying to make them feel valued and heard. They feel like talking to nurses is a safe space and they tell everything.
SARAH: And so that's really just one example of the role nurses can play in primary care. And there's been a lot of attention to this, of really looking at the role of the of the registered nurse. I know you've certainly given us a lot of thought around transition of care and other models. You know, tell us a little bit about the transition of care and how we are supporting patients when they are discharged from the hospital.
CHANEL: Of course, this was my MBA final project. But, this is very close to my heart because we're missing out on great opportunities. The evidence shows that patients are their most vulnerable from discharge to going home. So trying to figure out a way that we can get the patients in in those allotted times and it's generally 7 to 14 days post inpatient discharge.
And it's important to understand the difference. Just because they went to the ER, it doesn't necessarily fall under that 7 to 14-day window that they need to see their primary care. But if they have been inpatient, then you have to see them according to the insurance companies to stay in compliance with that transition of care metric.
One thing that I found doing the research is our providers are just busy. So, the best way to utilize this is using our licensed nurses to kind of lead that charge. When you look at what is identified as a transition of care appointment, it is really basic, discharge review, medication adherence, making sure that patients have the referrals they need, should they need to go follow up with a specialist, making sure that they have DME, which is their dural medical equipment, at home.
So, if this is all you're going through, you might do wound checks. The nurses can start that and they can also see the patient a little longer than a 15-minute slot. So they can actually have a 45-minute appointment to get to basically the meat of everything that's going on. And then a 5 to 10-minute follow-up with their primary care to be able to bill for that service.
So this gets the patients in faster, it allows for a more comprehensive overview of why they were in the hospital, helps to support follow-up, and creates a level of trust between the families and the patients and the healthcare provider. Plus it can close that bridge gap between the health care center and the hospital because now the hospital's care managers know exactly who to call.
We know the back story and then we can go head-on through to make sure that the patient has the best possible outcome. Because at the end of the day, that's what's important. To make sure that they did not have to return to the hospital within that 30 day window, which is cheaper for the health system, it's cheaper for the insurance company, and it gives the patient the best possible outcome.
SARAH: So there's really a lot of value to having the nurse manage really most of that transition of care visit. What are the implications in terms of billing? I mean, how, are health centers reimbursed for nurse visits?
What does that look like? I know that, you know, in the acute care setting, this is often a topic because nursing care is included in the bed rate. And so the actual nursing service is often lost, right? We don't see that reflected in billing. What does that look like in the community health center setting?
CHANEL: Unfortunately, nurses' time is not billable in reference to office visits. So, if it was a nurse that was going to the home, doing home care or doing patient wound care. That's billable time. Last year, they made it CHW's community health workers' time billable, yet nurse's second most expensive cost in clinics is still not billable, yet we can do so many things.
It would be ideal. The conversation is actually on the table with the Pennsylvania Board of Nursing, but it has not trickled down. When you look at the expense of having a nurse and I don't mean in dollars and cents, I mean in value as far as experience, education, the time for patient care. It's invaluable, but there is value added to it and we should be able to bill for that.
That will also make our clinics stronger. Yes, the provider can bill for it, but the nurses adding so much value to it that somewhere we should be able to bill for the nurses' time. That way, maybe more primary offices will take on nurses to support that. You know, medical assistants fall under the licensure of the provider, whereas nurses, we’re our own license and we must have a license to practice in the state of Pennsylvania.
So, if we have to have that license anyway, we should be able to bill for the time that we are spending with those patients. So, insurance companies should really take a deep dive, and see how being able to bill for ambulatory care, we bill for health coaches. The insurance companies definitely can get paid for their nurses to be health coaches.
We are essentially health coaches in the primary ambulatory office, and we should be able to bill for that time.
SARAH: Yeah, definitely seems like things align there to the benefit, again of reducing cost, and achieving the goal of that transition of care appointment. So this is an area to watch and an area of opportunity.
So, from a broader professional development viewpoint, what are some of the clinical trends that you're seeing, related to utilizing registered nurses in primary care, but also related to training, to preparing registered nurses to practice in primary care?
CHANEL: Working in primary care is not taught in the classroom, yet it is something that is greatly needed. When I came to PHMC, understanding that they were going to have nurses that we interviewed that had never worked in primary care, I created a book for the ambulatory care nurse to understand the transition of going from inpatient setting to primary care.
It explains their scope of work, which is very important. So you understand that your scope of work in primary care is very different than when you're working bedside, meaning there's a huge level of autonomy for nurses that work in primary care.
And there is a level of respect that comes from understanding vaccines for the children, understanding gerontology, and knowing how to do a DME and a prior authorization. These are things that at the bedside, you know nothing about. So when you come into this environment, this is where you learn how to navigate working with the insurance companies, how you navigate working with the city of Philadelphia, because if you do anything wrong with vaccines and vaccines for children that could shut down your entire program.
Ambulatory medicine is Monday through Friday, 9 to 5. No nights, no weekends, no holidays. So, it definitely has its perks. It would be exciting if we had the opportunity for more schools to get into showing their students what it's like to work in primary care.
Currently, I am working with Independence Blue Cross to have nurses come in during the summer to do their summer internship. One of the requirements that I asked for is for them to write an essay on why they would be interested in public health.
Public health is so important to our communities and the joy of having a nurse in each center. Some of our sites, we have two nurses. It's unheard of.
SARAH: And I mean, you just spoke about this directly, but really looking to the next generation of nurses. How, can we cultivate a pipeline of nurses that can be those registered nurses in primary care, that, growing workforce? Where are opportunities?
CHANEL: Funny you should ask. I had a meeting this morning with a charter school in Center City who would like to bring some students to shadow nurses for eight weeks. And they receive a stipend from the school for eight weeks for 3 hours a day, they get to shadow our nurses and the students who are selected for this program are interested in nursing. Getting them touched by nurses now is going to be vital. Because what we're finding is high school students are struggling still with math and science.
And nursing is essentially an extension of STEM. So this is an opportunity to get our Philadelphia schools into STEM programs at the high school level. The good thing is when they come this summer, I'll also have nursing students. So getting them in touch with nursing students who are actually going through the process of nursing school, and then they're working with nurses who are doing the job and leading the charge.
Reaching them younger, I think, will benefit us in the long run. Because when you get them at the college level, what they're hearing the most is you have to go in to be a nurse practitioner. When I taught, most of our students wanted to be nurse practitioners, but we're losing all the other nurses.
We're losing ambulatory nurses, we're losing bedside nurses, because it's the glory of being a nurse practitioner. We have to get back to, don't forget about the basics. We need our nurses. We need them in the schools. We need them at ambulatory centers. We need them in surgery centers. We need them out in the community.
SARAH: You captured so many important themes here and we often talk about having all professionals practicing at the top of their license. And that's very much true of the registered nurse, that a registered nurse is able to do so much and is often not being fully utilized in a practice setting, whether that's in primary care, frankly, or by the bedside.
So I think there are a lot of folks really paying attention to this and how do we maximize every professional in the care team and get to those quality outcomes, improve the patient experience, reduce costs, right? All of the things that we've been talking about. And the role of the registered nurse comes up again and again in those conversations.
I did want to add a plug when you mentioned nursing and the relationship to the STEM disciplines. So science, technology, engineering, medicine. There is a movement, and I wanted to call out to amplify nursing out of Penn nursing, Marion Leary and another colleague, Rebecca Love.
They have been great leading a coalition to get nursing recognized as a STEM discipline and see the benefit to that designation because you're right, these are the skills that are needed for nursing and that we want to prepare that pipeline and get those benefits.
So we're coming to the end of our show today. Any final thoughts do you want to share with our listeners?
CHANEL: Looking at nursing from where I started to where we are right now, I have had just some amazing opportunities. When I first had the, where do you see yourself in five years? This was not it. I thought I would still be at the bedside. I still thought that I would be, with my patients and I do miss them.
But given the opportunity to help nurses reach their fullest potential. Being able to mentor, I mentor nurses at Widener University and at CCP. I volunteer to help them understand, their nursing concepts to be a role model for people I don't even know. And then looking my daughter decided she was going to go back to school for nursing. And when she went she's giving these people my resume, and I said, well, you know, they were asking you about you and she said, well I needed to tell them all the wonderful things about you. You never know who you're touching, and nursing touches so many people, that you only need one to really feel like you've made a difference in the world.
So I am very happy with the choice that I made to be here. I hope that I am moving in purpose on purpose, and I hope that it inspires a new generation of nurses and nurse leaders to continue to lead that charge.
SARAH: Chanel, thank you so much for what you do every day at PHMC Health, what you do for the nursing workforce, what you do for us at NNCC. Just really appreciate your commitment and thanks for making time for At the Core of Care.
CHANEL: Thank you for having me. I've really enjoyed it.
SARAH: Special thanks to Chanel Hart for joining us. You can find our most current and past episodes of At the Core of Care, wherever you get your podcasts or at panursingworkforce.org. And if you're interested in learning more about the role of the registered nurse in primary care, check out our resource library at nurseledcare.org.
For more information about upcoming webinars and opportunities to obtain Nursing Continuing Education credits, log on to nurseledcare.org. On social media, you can stay up to date with us through our handles, @NurseLedCare and @PANursingWorkforce. At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Nursing Workforce Coalition and the National Nurse-Led Care Consortium. Thanks for joining us.
