Medical Home Primary Care RN's

kcmylorn · Feb 14, 2011

I'm an RN working in a family practice clinic in the medical home model. This is my first time working primary care after being a bedside RN in hospital enviornments for 30 years. I love the clinic. I was so fed up with the way hospitals are run.I don't like the way older experienced nurses are treated by management. I couldn't tolerate them any more. I worked many areas in hospitals over the years- med/surg.oncology(18 yrs)/tele(7yrs) cadiac surgical stepdown(2yrs) endoscopy(1 yr)/sameday surg(2yrs)ICU/CCU(6months)neuro(1yr), LTC (7months). Ive worked staff and agency- both travel and perdeim.

The medical home model is like the way pediatricians offices have been run for years(If you have kids- you know what I mean)If your child was not acutely ill- you did your mommy thing with OTC's, if the OTC's were not working you called the office- spoke with the PNP who decided if you needed to be seen and when, either that day or next day or week later, If they were acutely injured or ill( broken bone, bleeding/stitches- you went right to the ED) All care or decisions go through the primary provider then get referred out to specialists.This is triage-

Triage is what the RN's do @ the clinic I work at. Only RN's are legally allowed to triage. This is what is called t-con's or telephone consults. This is the bulk of our work load and it's over the phone. These t-con's are either symptom based, referrals, or medication refils. The symptome based can be anything from a runny nose or a profuse nose bleed. The Rn has to determine why- this is why this takes an RN an alot of experience. You must know what questions to ask, what sx go with what condition. You have to be able to hear what the patient is NOT telling you and you must ask- because you are on the phone and can't see them. There are protocals(standards of practice, some clinics have computer software on their computers with list of questions to ask like a receipe some do not(my clinic doesn't) Then you make a decision based on what you decide the patient is telling you- runny nose, what did they try at home, how long has it been going on, do they need an appt in 24hr or can they wait up to 7 days. Is the nose bleed because they have a hx of HTN, are they on meds, did they take their meds- they need to goto the ED immediately. Remember these are clinics- primary care clinics- no ED equipment for codes, we call 911. Referral based t-cons: the RN can put in the referral to the appropriate specialty if the patient has been seen for this problem and the provider just forgot to enter it in the computer. If this is a new problem and the patient has not been deen by the provider for it, then they need an appt. As the RN you have to decide, again, is this urgent, emergent or can it wait for a routine appt.( wanting a dermatology referral for acne lazer treatments are not an urgent or emergent condition!) Medication refils: Most medication refils are only done until the patient has their next appt- HTN, oral Hypoglycemics. No Way Do WE EVER fill controlled substances over the phone( including lyrica, ambien, even tramadol)- that patient needs an appt!!

We also have "walk-in Nurse clinic's- only for sore throat's, URI or UTI's(although the most infuriating part of the job is the 'check in' clerk's who make everyone who walk's through the door sound like they fit into one of these walk in and the patient's come in with fake coughing and runny noses and want us to think they are dying = manipulation( lots of this going on), so the patient doesn't have to wait for an appt. As the nurse walk in - the RN sees the patient instead of the doc. we do Vital signs, do a symptom based only assessment(if complaining of URI- listen to lungs, sore throat look in throat, get a throat swab), run our findings by the doc who is busy with the every 15 min. appt patient's who did call and wait for an appt.The doc will ginve us verbal orders, we enter them into the computer, do teaching with the patient- hand washing, cough and runny nose hygeine, fluids, rest and discharge them from the clinic.

The Rn's are utilized like APN's without prescriptive priviledges( which is why I love it)

Our clinic has Women's Health(GYN), mental health, peds, family(adult health. I have been filling in for the peds nurse when she is out. I am being moved to peds in the next few weeks( another new speciality for me in my old age) My saying is: since they kicked us old RN's out of the hospitals because we were too expensive- I don't want to hear any S**T as to "How come you can do all that" This is what happens when they kick us old nurses out of the hospital- we just become more diverse. So I will be able to add- primary care/clinic/doctor's office/ telephone triage- adult and peds.!!! Slave away all you new nurses!!!``

The pay right now for me is not good- it is $13/hr less than what my payscale would be in the hospital. I am grossely unpaid. This is what nurses are calling underemployed. I am hoping Obama care fixes the payscale for primary nurses- this is community/public health. You have to be able to fly alone and know what your doing. You must know your pathophysiology, pharmacology and assessment skills. You must be able to critically think and be solid at decision making. You have to like patient teaching beyond a pre written dischagre instruction handed to a pt in the hospital- the nursing instruction that is given comes from a vast personal data bank.

This is just my experience and I hope this answers your questions.