The clinic is operated by a nurse practitioner who sees posthospital patients and provides more intensive one-to-one education with the patient and his or her family members. The patients in Memphis are often uninsured and they pay minimal to no fees, depending on their financial situation.

The NP assists with medication acquisition, reinforces discharge education and coordinates follow-up primary care in the collaborating resident physicians’ clinic to address the multiple comorbid conditions these patients also face. In addition, the NP continues to follow the patients from a HF standpoint, coordinating her HF appointments to coincide with the resident physicians’ primary care appointments at subsequent visits. This further minimizes fees and makes the best possible use of the patient’s in-office time, thus reducing time lost from work and the patient’s out-of-pocket expense. 



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On-site clinics. A third treatment strategy that has been underutilized historically but has been gaining momentum in recent years is the on-site clinic. These clinics are located at the patient’s workplace. With an on-site clinic, the provider is at the workplace and readily available to the patient. Historically, these clinics have been used primarily for on-the-job injuries; however, that model has given way to a new concept of on-site clinics.14,15

Today’s on-site clinics are staffed according to the number of personnel served. The clinic can be staffed by a single NP for a few days each week, or it can be as fully staffed as any free-standing primary care office, complete with diagnostic capabilities.14 While on-site programs may start off with claims analysis, they often grow significantly once their value is demonstrated.1

Nationally, on-site clinics are gaining in popularity, going from 11% of companies with more than 500 employees in 2009 to 15% in 2010.16 Rather than using a fee-for-service model, on-site clinics typically negotiate a set fee contract, according to the needs of the company. Benefits for the employer include the immediate availability of medical care, minimal loss of employee time for medical appointments and increased productivity.

On-site clinics quite simply save time, and time is money.15 Some on-site clinics report as much as a 30% savings on group health costs as soon as the first year.14 The patient benefits by easy access to medical care and minimal time lost from work. There is no need to use vacation or sick leave for medical appointments. On-site clinics do not usually require a co-pay, and they are readily available to the patient.5,15-17

Although some companies encourage employees to use these on-site clinics as their primary care home, most patients do not. Instead, the clinic staff collaborates with the primary care provider for ongoing tracking and follow-up care.17 On-site clinics are the ideal place to monitor chronic diseases, such as HF, and to provide education to promote wellness.

Many companies, particularly those which are self-insured, have partnered with their employees in a wellness contract that enables individuals to save money on their insurance premiums as wellness goals are met. Working daily alongside employees, the provider becomes more than the person who sees them once or twice each year. On-site clinics provide an opportunity for the provider-patient relationship to grow into a stronger, more trusting bond that encourages compliance.15

The clinics also give the provider the ability to closely monitor at-risk patients and talk with them frequently without cost standing in the way. For medical conditions that have the potential for rapid deterioration, such as HF, an on-site clinic is ideal because early recognition of symptoms and prompt intervention can prevent what might otherwise become yet another hospitalization. Close follow-up care and education have already been shown to improve outcomes in HF patients, and on-site clinics are among the logical solutions.11

Conclusion


Albert Einstein said, “Insanity is doing the same thing over and over again and expecting different results.”18 Evidence-based guidelines have proven that timely interventions will make a difference in patients’ lives. The task now is to identify and break through the barriers that stand in the way of providing that care and making that difference.

With health-care costs out of control, the time has come to let go of the traditional models of patient care that are not working and start thinking outside the box.


Acknowledgment: The author wishes to thank Stephen Miller, MD, medical director for graduate medical education at Methodist University Hospital/University of Tennessee Health Science Center and Methodist Teaching Practice, for granting permission to identify their programs by name in this article.Amanda Ermis, RNC, MSN, FNP-BC, is an instructor at the University of Tennessee Health Science Center College of Nursing in Memphis. Sheila Melander, DSN, ACNP-BC, FCCM, FAANP, is a professor at the University of Tennessee in Memphis, whose area of practice is cardiovascular nursing.


References


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  3. Oh J. 10 proven ways to reduce hospital readmissions. Becker’s Hospital Review. September 21, 2011. 
  4. Fabregas L, Conte A. Little progress found in expensive hospital readmissions. Pittsburgh Tribune-Review. September 28, 2011.
  5. Welcome to first onsite Frankfort. Available at firstonsitefrankfort.com. 

  6. The art of patient care. Patient Compliance. June 26, 2009. 
  7. Herper M. The most powerful doctor you never heard of. Forbes Magazine. September 27, 2010.
  8. Prevention and treatment of heart failure. American Heart Association. June 13, 2011.
  9. Mann DL, Chakinala M. Heart failure and cor pulmonale. In: Longo DL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. Vol 2. 18th ed. New York: McGraw-Hill 2012:1901-1915.

  10. Lopes R. Chronic Heart Failure: The Basics. Clinical Ops Presentation. May 16, 2008. Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. 
  11. Jessup M, Abraham WT, Casey DE et al. 2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;53:1343-1382.

  12. Romeo, Ortiz, Miller, et al. Heart failure. Heart Failure Online Web site.
  13. Michael S. Heart health at home. Johns Hopkins Nursing. 2010;8:49.
  14. Klepper B. Onsite clinics within a competitive health care marketplace.
  15. Helfand D. More employers are offering on-site medical clinics. Los Angeles Times. July 3, 2011. 
  16. Micek K. CISD to open onsite employee health clinic. August 27, 2011. 
  17. Andrews M. Many workplace clinics offer primary-care services. Los Angeles Times. May 25, 2011. 

All electronic documents accessed July 12, 2012.