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A New Model of Care: A Nurse Practitioner-Led Complex Care Clinic Tessa Gresley-Jones BScN, MN, NP-Paeds Holland Bloorview Kids Rehabilitation Hospital University of Toronto, Lawrence S. Bloomberg Faculty of Nursing BACKGROUND Children with medical complexity are a small, but important group of children who have extraordinary needs across multiple sectors, exceptionally high care demands, and account for a significant portion of pediatric health care spending. Over the past four years, Holland Bloorview Kids Rehabilitation Hospital - Canada’s largest children’s rehabilitation hospital - implemented a Nurse Practitioner (NP)-led complex care clinic in order to provide high quality, safe and efficient care for this population, while increasing access to care within the Child Development Program. The PEPPA Framework was used to implement and evaluate the role. PEPPA FRAMEWORK: STEPS EIGHT & NINE THE PEPPA FRAMEWORK QUESTIONS CONSIDERED: •What are the needs and gaps in care identified by nurses & NPs, physicians, interprofessional team, clients and families? Long wait times for assessment & follow up Lack of community medical follow up for chronic health conditions Duplication of services between community, hospital & rehab Need for care coordination & support navigating the health care and school systems •Can an NP address those needs? What unique clinical background, knowledge and skills does the NP have? Paediatric NP hired into the role had experience working with children with disabilities and complex medical needs Expertise supporting children with technology dependence (g- tubes, tracheostomies, etc) Experience navigating the community and acute care system •What can an NP can offer in a clinical setting which is similar and different from what is already being offered? How can the NP’s expertise in health promotion and the treatment and management of chronic or complex health conditions best be utilized? Similar: Family centered medical & developmental follow up based on the International Classification of Functioning, Disability & Health Different: NP-led clinic for a subset of children followed in the larger Neuromotor Paediatric Rehab program – children with cerebral palsy who have care coordination needs and complex medical +/- psychosocial concerns. •How will all NP Core Competencies be utilized? (Clinical, Leadership, Collaboration, Research). Quality improvement initiative – implementing a clinical practice guideline, developing tools and resources for nurses Nursing leadership – participation in Nursing Practice Council Research – contribution to a systematic review on cerebral palsy and chronic pain PEPPA FRAMEWORK: STEPS ONE - FIVE PEPPA FRAMEWORK: STEPS SIX & SEVEN Policies & Resources: Whether official policies are required in your setting or not, it is crucial to ensure structures & resources are in place to allow the NP to practice to full scope in the given context. Physicians may also benefit from policies & resources – in order to clarify their collaborative relationship with the NP – especially for physicians with little experience working with NPs. Medical Directives: Recent legislative and regulatory changes in Ontario, Canada have lessened the need for medical directives. Still a medical directive was required for some diagnostic tests. Collaborative Practice Agreement: This document has been helpful to clarify when and how NPs and physicians will consult and collaborate. Includes: Consultation process (when & how); Referral process (if physician referral is required to specialists); Transfer of accountability (absences & after hours); Scope of practice & authorizing mechanisms (medical directives). Education & Support: Ensure adequate time for NP orientation (dependent on NP experience & clinical area) Support to attend conferences & workshops Opportunity & protected time to engage in non-clinical domains of NP practice Adequate support staff, space & equipment. System to capture NP workload Support & collaboration from management Start small Have a vision Leadership opportunity early on Mentorship Sufficient time for orientation Lack of administrative support & physical clinic space Reporting structure for NP does not align with NP & organizational needs Legislation & regulation (billing procedures in hospital; limitations to scope) Driving & Restraining Forces Evaluation of the NP-led Complex Care Clinic Client & Family Centered Care Interprofessional Collaboration Client & Family Centered Care Interprofessional Collaboration Access to Care Efficient Care • Client Satisfaction Questionnaire (CSQ-8) • Family Professional Partnership Scale (FPPS) • Provider Collaboration Survey (PCS) • # of visits / new referrals (volume) • # of waitlist clients seen by the physicians as a result of NP seeing complex follow ups • Frequency of follow ups / telephone contact • No show rate • Frequency of follow ups • Frequency of telephone contacts • Wait time Strategic Direc+ons 20122017 •Transform Care •Lead the System •Accelerate Knowledge •Inspire our People Access to Care •Volume: 106 attendance days over 8 months (Jan-Aug 2012) o26 new referrals; 80 follow-up clients / 62 unique clients oAverage of 15 visits per month •Average frequency of follow up: 1.7 visits (range from 1-6 visits) •Number of waitlist clients seen by physicians as a result of NP seeing complex follow ups: 62 Efficient Care •No shows: 11% •Phone contacts: Average of 7.5 hrs/week of telephone contact. 9-11 contacts with families per week. •Wait time (wait 2): 0 days References: 1.Blue-Banning, M., Summers, J.A., Nelson, L.L., Frankland, C, Beegle, G.P. (2004). Dimensions of family and professional partnerships: Constructive guidelines for collaboration. Exceptional Children, 70(2), pp.167-184. 2.Bryant-Lukosius, D., DiCenso, A. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Nursing and Health Management and Policy. 48(5), pp530-540. 3. Berry, J.G., Agrawal, R.K., Cohen, E., Kuo, D.Z. (2013). The Landscape of Medical Care for Children with Medical Complexity. Children’s Hospital Association, Alexandria, VA, Overland Park, KS. 4. Canadian Nurses Association (2010). Canadian Nurse Practitioner Core Competency Framework. Ottawa, ON. 5. Cohen, E., Berry, J., Camacho, X., Anderson, G., Wodchis, W., Guttmann.A. (2012). Patterns and costs of health care use of children with medical complexity. Pediatrics, 130(6), pp.1463-e1470. 6. Government of Ontario (2009). Health Force Ontario: Nurse Practitioners. Retrieved 26/09/2011 from www.healthforceontario.ca . 7. Larsen, D.L., Attkisson, C.C., Hargreaves, W.A., Nguyen, T.D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2(3), pp. 197-207. 8, Way D., Jones L., Baskerville N.B. (2001). Improving the effectiveness of primary health care through nurse practitioner / family physician structured collaborative practice (NA342). Final report to the Primary Health Care Transition Fund. University of Ottawa. Caregiver Response Rate N=24 / 55.5% response rate Availability “Main contact” “ I always go to her” “Her availability and support takes some pressure off me as a parent” Knowledge “Her knowledge helps us deal with new situations” “Very knowledgeable of resources” “Makes the best decisions for my son” Client & Family Centered Care “Explains things well” “Pays attention and takes time which is needed by my child “Provides me with hope and confidence for my child” Themes from Caregiver Comments (CSQ-8) Summary of NP Clinic Impact •Increased Access (waitlist clients): MDs able to see more new clients from the waitlist. •Increased Access (complex clients): Complex clients, who require more medical care, developmental support & care coordination have increased access to care. •Efficient Care: Care occurs when/where is makes most sense for the family: hospital, home, via telephone / email. No wait times. Low no show rate. •High Client & Family Satisfaction •High Interprofessional Team Satisfaction COMPLEX CARE CLINIC DESCRIPTION •Medical home model: hub where clients & families receive timely provision and access to coordinated care. NP is the ‘key contact’. •Referral criteria: (1) chronic, severe health conditions (e.g. cerebral palsy); (2) substantial health service needs (e.g. multiple care providers across care locations); (3) high health care utilization (e.g. multiple hospitalizations or appointments, use of home care services); and (4) major functional limitations (e.g. children who are non-ambulatory and/or technology dependent). •Access & Availability: Visits occur at hospital, home, school or specialist appointment, depending on need. Telephone / email availability 5 days/week. •Care Plan: Created and kept up to date for each client. •Collaboration & Consultation: With interprofessional team / primary care / home care / schools / acute & rehab specialists. •Advanced Care Planning: Clear goals of care.
