P3.A004: Implementation of a Nursing Pool Intervention to Enhance Well-being Among Pediatric Primary Care Clinicians

Background: Children’s Primary Care Medical Group (CPCMG) is a 164-clinician, physician-owned pediatric practice serving 272,000 patients at 28 sites throughout San Diego and Riverside counties. From 2019 to 2023, the prevalence of clinician burnout increased from 29% to 45%, respectively. We identified an increased volume of clinician-directed InBasket patient messages contributing to burnout, highlighting an opportunity to enhance wellness by reducing the number of electronic messages initially directed to clinicians.

Methods: The goals were to: 1) Create a structure in which remote care nurses may triage My Chart Patient Advice Requests in the InBasket 2) Decrease "Work outside of Work" and "Time on Inbox" for clinicians 3) Enhance clinician wellness by decreasing message volume going directly to the clinician and 4) Establish a mechanism by which clinicians may to refer complex patients for care coordination. The Population Health Team initiated a pilot project in which Patient Medical Advice Requests (PMAR) messages were directed to a "pool" of Registered Nurses working remotely (“The Remote Care Team"). Care Team nurses responded to the patient directly by triaging symptoms, reinforcing treatment plans, and answering medication questions. Nurses then forwarded these messages to the clinician, as appropriate, directed them to administrative or education pools (i.e., appointment management or immunization information), or directly scheduled an appointment using a link for self-scheduling. This pilot included a "refer-in" option in which the clinician could refer complex patients for additional care coordination. During the first year of implementation, the intervention expanded to include 25 offices at CPCMG.

Results: The percentage of PMAR messages going directly to the clinician changed from an average of 75% at pilot implementation (January 2023) to 11.1% (January 2024). Efficacy was measured by looking at EPIC Signal data using Time on EHR outside of scheduled patient hours (WOW8) and Time in InBox (IB-Time8) per 8 hours of patient scheduled time. From January 2023 (4 offices in pilot) the WOW8 and IB-Time8 were 98 and 48 minutes/ day/ clinician, respectively. As of January 2024 (25 offices in pilot), 1-year after implementation, the measures were 98.4 and 44 minutes/day/ clinician respectively. During this time referrals for care coordination increased from 50 to 70 patients.

Conclusion: Within one year, our novel Remote Care Team model substantially reduced InBox time and the volume of PMAR messages directed to clinicians, and increased the number of patients referred for care coordination. Future efforts will focus on expansion of the remote care team to other patient care domains—including medication refills, standing orders, and mental health—as well as optimization of nurse education and EMR generated protocol development. Additional efforts will include increasing referrals for care coordination of highly complex patients. Future efficacy metrics will include tracking "Work outside of Work" perceptions and burnout through survey deployment.