Author: Andrea Mosher, CPNP

The demand from the healthcare system on providers such as nurse practitioners appears to be growing daily. Whether it's driven by increasing patient volumes or the heightened requirements for insurance reimbursement, it can seem like an ongoing game of catch-up. While the ultimate goal of a healthcare system is to create high-quality and high-value care for its consumers, most of the responsibility ultimately falls on the physicians, nurse practitioners, physician assistants, nurses, and support staff. With ever-changing technology advancements and the continuous evolution of health disparities, it is critical to avoid the "it's always worked, so why change it now?" mentality. At the same time, attempting to achieve these goals without a proper plan can be exhausting, expensive, and inefficient. Therefore, it is important to understand the purpose of quality improvement and how to effectively execute performance improvement programs.

RELATED: Keeping Your Sanity: How to Prevent Nurse Practitioner Burnout

Purpose of Quality Improvement

Some people question why providers, clinics, and hospital systems even worry about quality improvement, as they perceive it as "fixing what isn't broken." However, that is far from the truth. There are several reasons why quality improvement should be at the forefront of healthcare providers' radar, as it is imperative in the following:

• Improving the health of the population
• Enhancing the patient experience and outcomes
• Improving the provider experience
• Reducing the per capita cost of care

How to Design a Project

Designing an improvement project is a relatively simple process, and several factors should be considered beforehand.

• Clinical Setting: What is the available timeline? Which strategy for performance improvement is appropriate for this particular clinical setting?
• Current Performance: Are there any easily identifiable areas of improvement? Which performance aspect should be prioritized? 
• Patient Population: What are the major features of the clinic's patient population (i.e. age, race, gender, health disparities)? Which intervention will have the most positive impact on the majority of the population?
• Institutional Commitment: Who will be at the forefront of the project? Who are the key stakeholders? Will this require a financial commitment?

RELATED: New Graduate Nurse Practitioners: Keep Learning to Build Confidence

Plan-Do-Study-Act

A classic approach to the design and implementation of a quality improvement project is the Plan Do Study Act approach. This multistep process systematically breaks down the process and allows for proper monitoring of progress:

Ideas to Implement Into Daily Workflow

Primary care NPs can take the following steps to make concrete quality improvements in their offices:

1. Improving Annual Screenings in Wellness Exams: An annual screening can be time-consuming to complete, and time is not readily available in the medical world. However, continuously screening patients is imperative. Depending on the Electronic Health Record capabilities, patients may receive a request via online portal, email, or physical mail to complete and return by their appointment time. 

2. Improving Slot Utilization in Primary Care: Effectively utilizing all available appointment slots is important to providing quality care and access to a patient population. One approach to improving slot utilization is to create a plan that schedules patients as close to the desired time as possible, rather than several days or weeks in the future and sending reminders. Additionally, in the case of cancellations, it is imperative to prioritize patients who were scheduled further out than clinically appropriate.

3. Increasing the Consistency and Efficiency of Medicare Annual Wellness Exams: Annual Medicare wellness exams are often lengthy, tedious, and time-consuming. However, they are pertinent for the geriatric patient population. To ensure that all patient appointments are consistent and efficient, a clinic may choose certain staff members to serve as the cardinal staff members who manage these appointments. Additionally, creating a checklist or flowsheet for these visits can keep them organized and boost the efficiency of each appointment. 

4. Maximizing Patient and Provider Experiences by Improving Appointment Agendas: Creating appointment agendas can be an effective way to keep appointment times on-track and in turn allow a provider to see a larger patient load. A typical agenda design includes:
   • Asking the patient to list their concerns
   • Planning the visit by prioritizing immediate issues and saving the other concerns for a follow-up appointment
   • Reiterating the plan with the patient
   • Concluding visit and discussing follow-up

Continual monitoring of primary care workflow leads to efficient patient appointments and potentially better patient outcomes. Appropriate workflows can also reduce the incidence of provider burnout, as providers know what to expect for the workday and can prepare accordingly. If you already have a great workflow in your clinic, check out this list of other performance improvement projects.

Nurse practitioners (NPs) are typically hyper-focused on the health and well-being of their patients, constantly encouraging them to eat nutritiously, exercise regularly, stick to a regular sleep schedule, and participate in stress relief activities. However, when was the last time you practiced what you preached as an NP? With healthcare professionals pulled back and forth between balancing patients and administration at work and family and daily responsibilities at home, it is no wonder that so many providers suffer from burnout without even knowing it. From family care to acute care, burnout does not discriminate in the healthcare field.

While preventing burnout is important in any role, it's especially pertinent when working in healthcare during a pandemic. It has become increasingly crucial for providers like NPs to recognize what burnout looks like, the different causes, and how it can be prevented and treated. This is not only valuable for providers, but for the safety and well-being of patients as well.

Causes of Nurse Practitioner Burnout

Hours

Depending on the employer, providers may or may not have a set schedule for work. However, the scheduled hours are not the extent of the hours worked. NPs could come in early, leave late, or work through lunch, which ultimately cuts into their availability to care for themselves.

Low Control of Daily Pace

In both hospitals and outpatient environments, NPs have little to no control of their patient load and acuity. Providers who work in hospitals or urgent care facilities have no say over who walks in and is admitted to their service. Outpatient providers may have a daily schedule of the patients who they expect to see that day, but it often changes throughout the day.

Time Pressures

Regardless of the employer, there is always an expected number of patients that an NP will care for during a shift. Oftentimes, the allotted time for patient care is not enough to thoroughly examine and address all of the patient's concerns. This can ultimately increase the amount of follow-up appointments, further filling up an already tightly-packed schedule. Alternatively, an NP may try to address all of the patient’s concerns in one visit. However, this approach typically causes delays in other patients' care or scheduled appointments.

RELATED: 5 Must-Have Apps and Tools for Nurse Practitioners

Electronic Health Records (EHR) and Documentation

EHRs are a vital asset for billing, legal liability, and continuity of care. Outside of caring for patients, documentation is the next most important job for providers. This means that everything must be completed accurately and succinctly in a timely manner. However, the real challenge for NPs is finding time to complete this work with no breaks between patients.

Symptoms of Nurse Practitioner Burnout

1. Mental exhaustion
2. Emotional exhaustion
3. Physical exhaustion
4. Depersonalization
5. Insomnia
6. Sadness or irritability
7. Increased vulnerability to illness
8. Decreased sense of personal accomplishment

It is important to understand that the responsibility of preventing and treating burnout does not fall solely on the employer.This process requires some level of effort from the provider as well. Here are some ways to prevent burnout from occurring, or treat it if symptoms have already begun.

Nurse Practitioner Burnout Prevention/Treatment

Schedule 10-30 Minutes of Exercise Daily

Physical activity strengthens the cardiopulmonary and musculoskeletal system and releases endorphins. This boosts both physical and emotional health. With time constraints, squeezing in small exercise breaks may be more feasible than developing one longer exercise routine.

Seek Support

Healthcare burnout is very common, and finding a colleague who may be going through a similar experience can offer a great source of support. Discussing your frustrations and feelings with a counselor or psychologist can also help relieve burnout. These conversations can be conducted in an office or virtually.

Evaluate Work Options

If there are no promising changes after sharing your thoughts on imbalances in expectations, it may be time to start looking for a new job or employer.

RELATED: How to Negotiate Your NP Contract

Staff Meetings to Evaluate Office Flow

Engage in open discussions with support staff to determine what type of patient flow works best in your office or unit, ensuring that it is as optimized as possible. Also, aim to schedule small breaks throughout the day to complete documentation and other administrative tasks.

Streamline EHR Flow

Create smart sets and favorites of orders, diagnosis codes, and patient instructions to streamline the documentation process. Consider the possibility of hiring a scribe to help reduce the strain of documentation.

***

Nurses and nurse practitioners are the most trusted professionals in America, but this high honor can lead to a significant amount of pressure. While we should continue to provide the best care possible to our patients, it's important to take notice when it's negatively affecting our physical, mental, and emotional health.

Being a nurse practitioner is so much more than just assessing, diagnosing, and treating patients. Providers are also regularly responsible for breaking bad news, calming frustrated patients, and explaining the complicated world of treatment plans based on accessibility and insurance requirements. This is a daunting task to add to the already demanding world of medicine. So, what are some approaches that can help lighten this burden? Understanding the source of the problem and creating a game plan to ease the situation is key.

The Root of the Problem

Difficult patient and family interactions come in a variety of shapes and sizes, and they go beyond bearing bad news or discussing potentially ominous test results. Challenging interactions most frequently stem from discrepancies in expectations, perceptions, and communication. Common real-life challenging interactions include:

• Patients feeling left out of treatment decisions 
• Patients not feeling heard or listened to
• No concrete answers or diagnosis after a workup
• Treatment non-compliance 
• Expensive treatment options
• Delivering bad news

Challenging patient interactions are a multifaceted experience, and these situations aren't only about the provider and patient. In reality, they include a variety of internal and external considerations. Factors that can affect the difficult interactions include:

1. Environment: The office, clinic, or hospital may not always be able to accomodate the ideal privacy and comfort setting for these discussions.
2. Audience: The environment where the interaction occurs may have a larger or smaller audience than the patient would like. Patients may or may not want family present, and additional staff members can occasionally be present as part of their daily role. 
3. Empathy: Long working hours, an increased workload, and the frequency of certain interactions may invoke an unintentional lack of empathy from the healthcare provider. 
4. Resources: A lack of staffing, specialists, and diagnostic testing can lead to long wait times, drawn-out workups, and delays of treatment. 
5. Nonverbal communication: Nonverbal communication is equally as important as verbal communication. However, this form of communication is open for interpretation and can lead to incorrect perceptions.
6. Ambiguous/complicated plans: Treatment plans are not a one-size-fits-all strategy. Sometimes, a full treatment plan cannot be created as it depends on diagnostic results or responses to first-line treatment. These incomplete plans can cause anxiety in patients and families as they do not know what to expect. Overly complex treatment plans can also be overwhelming and confusing to patients and families, potentially encouraging noncompliance. 

While the primary goal of a difficult interaction is to create a positive outcome for the provider and patient, that's not always the case. Potential worst-case scenarios include:

• Consulting "Dr. Google"
• Frustrations that lead to threats of legal action
• Failure to accept the diagnosis
• Lack of trust related to no diagnosis, despite having signs and symptoms
• Noncompliance
• Negative focus on continuing symptoms, as opposed to recognizing progress

RELATED: Nurse Practitioner Practice Authority

Managing Difficult Patient Interactions

Nurse practitioners experience difficult interactions on a regular basis. Unlike the doctors and nurses on television, healthcare providers cannot rely on a writing team to deliver an eloquent, jaw-dropping speech to patients and families. So, what's the best way to manage these situations? Should we just accept that they are bound to occur and we have no control over them? Absolutely not. Managing these situations might take a lot of work on our part, but it will ultimately make our daily practice less stressful. Here are some ways to prevent and control a potentially difficult interaction:

1. Plan your interaction with the patient or family.
2. Consult a colleague or seek additional training before the interaction.
3. Create a comfortable environment by introducing all present parties, sitting with the patient, and maintaining eye contact.
4. Pay attention to your nonverbal communication, as well as the patient and their family. 
5. Ensure everyone's safety and maintain situational control.
6. Use empathy and active listening to encourage a patient's emotional control.
7. Provide multiple options to focus on solutions and resolve areas of disagreement.
8. Avoid using language such as:
   1. "I'm afraid I have bad news."
   2. "This is a terminal disease."
   3. "You are lucky it is only _________."
   4. "There is nothing left for us to do."

After a difficult interaction, it is important to reflect upon the situation – whether it went well or not. If it was a positive discussion, it's helpful to take note of the particular approach and utilize it for future interactions. If the encounter with the patient and family did not go as planned, it's critical to note what didn't go well and develop new approaches for future patient conversations.

Difficult patient interactions will inevitably occur in a nurse practitioner's career. However, it is the NP's responsibility to serve as a trusted resource in their patient's care. Understanding which factors create difficult interactions and customizing the appropriate approach to the patient's needs can help develop a dynamic that fosters the best possible health outcomes.

From insurance reimbursement and billing to coding and audits, these responsibilities can leave any healthcare provider with goosebumps – especially those who work in or own their own private practice. The most stressful part, in relation to insurance reimbursement, is that most healthcare providers like nurse practitioners are not formally trained in billing and coding and work in a clinical setting or facility with no certified billing and coding specialists. Luckily, there are a wide variety of resources available to help decode this unfamiliar territory.

Coding Basics

Accurate coding is critical for insurance reimbursement, succinct documentation, and identifying clinical care gaps. The Healthcare Common Procedure Coding System (HCPCS) codes and International Classification of Diseases, 10th Revision (ICD-10) codes serve as the building blocks of medical coding.

• HCPCS Level I codes: These codes are used to describe medical, surgical, diagnostic, and other types of medical services. In addition, there are modifiers that help identify alterations to HCPCS codes.
  • Category I: Common procedures
  • Category II: Performance measurements
  • Category III: Emerging technologies
• HCPCS Level II codes: These codes are used to describe products, supplies, and services provided during an encounter.
• ICD-10 codes: These codes are used to describe the reason for a patient encounter or outline a patient's characteristics, and are essential for identifying common diagnoses in a medical practice. They notify the insurance payer of the medical necessity of the visit.

Evaluation/Management Coding

Evaluation/Management (E/M) coding is the core of healthcare billing and insurance reimbursement. Understanding E/M coding can help maximize the insurance reimbursement of a practice and reduce stress levels during audits. These codes are based on several factors:

• The patient's history
• The patient's physical exam
• The provider's medical decision making
• The appointment time, specifically if the provider spent 50% of the visit coordinating care or counseling

There are different levels for the aforementioned factors, which decipher which E/M code to use.

1. History
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
2. Physical Exam
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
3. Medical Decision Making
   1. Straightforward
   2. Low complexity
   3. Moderate complexity
   4. High complexity

The level of complexity related to medical decision making depends on the number of diagnoses and management options, the complexity of the patient data that was reviewed, and the risk of complications or morbidity/mortality.

Transition of Care Billing and Coding

Transition of care visits are an efficient way to support the continuity of care after a patient is discharged from a skilled nursing facility/nursing facility, long-term acute care hospital, rehabilitation hospital, acute care hospital, or observation stay in a hospital. A transition of care visit can only be billed one time per patient in a 30-day timeframe, and can be billed for both new and established patients at a particular clinic.

Transition of care visits can be billed using two different codes.

• 99495-This code can only be used if the patient has been contacted within two business days of their discharge, the medical decision making is of moderate complexity, and there is an in-person clinic visit within 14 days of the discharge.
• 99496- This code is used if the patient has been contacted within two business days of their discharge, the medical decision making is of high complexity, and there is an in-person clinic visit within seven days of the discharge.

Medicare Wellness Coding and Billing

Medicare wellness exams go beyond a typical annual adult wellness examination. In addition to focusing on a patient's wellness, these exams involve a thorough screening centered around disease prevention. The exam also takes a more comprehensive look at the patient's vital signs, medical/family history, and health risk assessments including their emotional and psychological well-being to develop a personalized prevention plan. Many types of healthcare providers can complete these wellness exams, including:

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Registered dietitians
• A team of medical professionals with an overseeing physician

RELATED: Complete Guide to the Adult-Gerontology Nurse Practitioner Specialty

Pediatric Coding and Billing

Accurate coding for the pediatric population is similar to the process for the adult population with several additional considerations including behavior screenings, developmental screenings, and vaccine administration. Another complication is that not all of these screenings and vaccines are completed at every age. Each well child examination typically has different screenings and different vaccine administrations or they may not have any vaccines at all. That's why it is important to follow the recommendations of Bright Futures, which establishes guidelines that insurances follow.

RELATED: Complete Guide to the Pediatric Nurse Practitioner Specialty

Initially, the billing and coding world can be daunting and confusing. Luckily, there are a variety of resources available to help providers make sense of this information. In addition to online resources, there are several textbooks and conferences that can strengthen a provider's knowledge of accurate billing and coding. Accessing the right resources can help providers boost their understanding, which leads to more efficient documentation, increased reimbursement, and decreased stress during chart audits.