Chronic care at retail clinics?

[msn-fnp09]

I was at the local Walgreens pharmacy, waiting to pick up my prescription, and I was browsing the list of services offered at the clinic inside the store. I noticed that the options include diagnosis and treatment of chronic illnesses, such as diabetes, hypothyroidism, hypertension, depression, and COPD. Is this really a good idea?

Do any providers here work in a retail clinic that provides chronic care services? What has been your experience with this? Do patients really go to these types of clinics for these services? What does everyone else think of this practice?

I absolutely think that these illnesses are well within the scope of the nurse practitioner to diagnose and treat in the primary care setting, unless they are truly complicated, in which case any prudent PCP would refer them to a specialist. It just seems like a bad idea to offer these services as part of a menu of specific services, next to sore throat and flu. What kind of follow-up will these patients have? What kind of evaluation? If a patient can go to a store clinic for these types of services, does it not discourage them from establishing a PCP? If there is no PCP overseeing their overall health, is something not bound to get missed?

Most of the in-store clinics I have seen have only one person working on any given day. Not to mention, a seemingly-endless list of patients waiting to be seen. Some of them have an assistant, but most do not. How can a solo provider manage all this?

Just really curious to hear what others think of this practice and if anyone has experience to share.

[BostonFNP, APRN]

Thanks for your post, well said. It does represent a large change in the current primary care paradigm; one could easily see why physicians would be concerned about if, at least from a financial angle.

As a PCP for a panel of complex chronically ill patients, I would have some concerns about my patients as well, but not from the perspective of concern about the NP being able to competently handle the patients (with one caveat, below) but rather from a systems perspective. The only retail

clinic I have around here is a fairly restricted algorithm-based clinic. I would be concerned about things like how patients make appointments for follow up visits while maintaining the "walk in" style, how clinic NPs interact with local specialists, whether clinic NPs get admitting privileges at local hospitals, how prior auths are handled, what chronic illnesses with be included and excluded (ie can clinic NPs manage diabetes but not diabetic neuropathy or renal insufficiency, manage hyperlipemia but not CAD/PVD, etc).

The one caveat I have with the above statement is concern only for those NPs that have been practicing for years and years in algorithm-based retail clinics all of a sudden being expected to start reading films and interpreting labs and ordering echos as that may be well outside their comfort level.

It is a wave of the future that's for sure, you should be proud to be surfing it in.

[coast2coast]

Really interesting to hear this perspective, thanks for sharing.

I always wondered about ability to refer out from this setting. It sounds like you have an official referral network? What about labs and referrals for uninsured patients?

[PatMac10,RN, RN]

So I work in one of the clinics at Walgreens and feel I can therefore address this topic. First. walgreens is just beginning to delve into chronic care management and it is not something they have done without a lot of thought. Yes, we do emergency refills etc but the chronic care management is beyond this, obviously. As we all know, nurse practitioners are well trained to manage chronic conditions. Just because it is being offered in a convenient care setting does not mean the standards change. NPs at Walgreens have the capability to order labs, order EKGs, make referrals, do POC testing in addition to outpatient labs etc. I am not limited in my ability to appropriately manage a chronic care pt because I work there (I cannot speak for other convenient care companies). Also, my patients can make appointments and they can choose to see me or my coworker. Our clinic is managed by 2 NPs and we rotate days. So, there is consistency in providers for our patients. We are there EVERY day of the year except Christmas and Thanksgiving so we are very available. Our patients have a call center to call if they need to talk to a provider and they get a call back the same day from the NP working. Also, the particular clinic I work at is the most busy (for Walgreens) in our area and I still feel this is manageable. Keep in mind that, despite the ACA, there are still a lot of uninsured or underinsured patients out there and we are often a more affordable option for patients that will not go to a physician practice because they cannot afford it. In addition, because we work in the community, a lot of people get used to us and feel comfortable coming to us instead of a physician practice. Obviously, if a patient is beyond what I feel comfortable managing, I do encourage them to get hooked up with a PCP. We are NEVER trying to take patients from their PCP, we simply are offering another option for those who would otherwise not go anywhere. Having said all of that, I feel like I should "confess" that when I first took this job out of convenience a few months back (got married, moved an hr away from my previous practice) I felt like I was taking a "lesser" job because it was located in a store. I could not have been more wrong. Again, I can only speak for Walgreens, but I will say that they really, really push evidence based practice and guidelines, following HEDIS guidelines, appropriate billing and coding etc. I get weekly chart reviews from my collaborating physician, quarterly peer reviews, weekly reviews of my billing practices etc. In addition, Walgreens does NOT use algorithms to tell the NP what to prescribe, labs to order etc like some other companies do. I decide how to manage my patients, no one else tells me what to order, pressures me to order antibiotics etc (in fact quite the opposite). I'm actually glad I made the change and work here! I[/quote']

I really appreciated this take on the situation. Then again, I've always liked the Idea of convenient care clinics. I like the concept of bringing the care to the patients. I think it's pretty innovative,

Sent from my iPhone using allnurses.com

[Juliefin, BSN, MSN, APRN, NP]

Hi everyone, to answer a few more questions. Patients can make appointments online or at our Kiosk but the system limits appointment slots to four a day to save the space for walk ins. The NP can override the system at any time and add additional appointments if needed. We don't have an official referral network set up yet but I'm pretty fortunate that I work in the Cleveland area so we have pretty easy access to specialists through the referral centers of both The Cleveland Clinic and University Hospitals of Cleveland. We have a few primary care groups that refer their patients to us for acute visits and I often refer patients without a PCP to those groups to get established with a PCP, when needed. Labs etc for uninsured remains a problem which I've been brainstorming about he to manage. I'm considering us contacting our labs we usually use to see if we can get some discount for private pay patients to help ease the burden but so far no good answer on that. We do get some prior auths and would be responsible for doing those ourselves (although I did that at my old office practice too). Also, you are right- no admitting privileges so any pt we see who needs hospitalization would have to go through the ED and be cared for by a hospitalist (same in my old practice as well). It definitely is new ground for us and i don't think it will ever be a large part of our patient base but I'm glad it's an option for some people. It still needs some clarification, in my opinion, but I think it's a good move. Just remember, if you want to try working in convenient care clinics but are like me and don't want algorithms, consider Walgreens because we do NOT have them!

[malamud69, BSN, RN]

Interesting....I can read and understand my own lab results...there is an almost unlimited amount of information at hand out in the world concerning most medical conditions....I understand pharmacology...I can Dx. myself! Why in this day in age would-do-we even need to go see a PCP and spend an abhorrent amount of money to be told something-if you are of that mind-that you could figure out for yourself....(Oh yes...no license...ugh)ask any MD I know and almost any one of them would tell you that all the physics and Bio chem etc...etc...they had to know (to be weeded out) has nothing to do with the art of Dx. It aint rocket science if you are of that mind. My point being...why not do it through the clinic? especially when you are lucky if an MD sees you for than 5 minutes...how in the heck is that good care...Nurses are and should be bolstered toward more of the medicine...an amorphous amalgam and paradigm shift must/is coming!

[BostonFNP, APRN]

Interesting....I can read and understand my own lab results...there is an almost unlimited amount of information at hand out in the world concerning most medical conditions....I understand pharmacology...I can Dx. myself! Why in this day in age would-do-we even need to go see a PCP and spend an abhorrent amount of money to be told something-if you are of that mind-that you could figure out for yourself....(Oh yes...no license...ugh)ask any MD I know and almost any one of them would tell you that all the physics and Bio chem etc...etc...they had to know (to be weeded out) has nothing to do with the art of Dx. It aint rocket science if you are of that mind. My point being...why not do it through the clinic? especially when you are lucky if an MD sees you for than 5 minutes...how in the heck is that good care...Nurses are and should be bolstered toward more of the medicine...an amorphous amalgam and paradigm shift must/is coming!

Are you suggesting people should google symptoms and treat themselves?

[BostonFNP, APRN]

Hi everyone to answer a few more questions. Patients can make appointments online or at our Kiosk but the system limits appointment slots to four a day to save the space for walk ins. The NP can override the system at any time and add additional appointments if needed. We don't have an official referral network set up yet but I'm pretty fortunate that I work in the Cleveland area so we have pretty easy access to specialists through the referral centers of both The Cleveland Clinic and University Hospitals of Cleveland. We have a few primary care groups that refer their patients to us for acute visits and I often refer patients without a PCP to those groups to get established with a PCP, when needed. Labs etc for uninsured remains a problem which I've been brainstorming about he to manage. I'm considering us contacting our labs we usually use to see if we can get some discount for private pay patients to help ease the burden but so far no good answer on that. We do get some prior auths and would be responsible for doing those ourselves (although I did that at my old office practice too). Also, you are right- no admitting privileges so any pt we see who needs hospitalization would have to go through the ED and be cared for by a hospitalist (same in my old practice as well). It definitely is new ground for us and i don't think it will ever be a large part of our patient base but I'm glad it's an option for some people. It still needs some clarification, in my opinion, but I think it's a good move. Just remember, if you want to try working in convenient care clinics but are like me and don't want algorithms, consider Walgreens because we do NOT have them![/quote']

It sounds like you are making great strides.

I would worry a bit about only having four follow-up spots per day on a schedule if the clinic is planning on managing even a modest panel of chronic patients, but that could be adapted as panels grew I'm sure.

What chronic illness are being covered?

[sirI, MSN, APRN, NP]

Are you suggesting people should google symptoms and treat themselves?

I, too, am wondering if this what you mean? You are being factious, ,yes??

[Blindsided]

I really find this topic interesting. I would like to hear from the CVS side which I believe uses algorithms. Thanks.