Date post: | 14-Dec-2014 |
Category: |
Health & Medicine |
Upload: | australian-primary-health-care-nurses-association |
View: | 1,177 times |
Download: | 0 times |
Using Nurse Led Clinics
A Team Approach to Managing Preventative
Health & Chronic Disease Care in General Practice
Karen Booth RN
About General Practice
• Changing workload• GP shortage• Complexity of care• Complex Govt funding for GPs • Computerisation of general practice • New model of primary care using
a Team Approach for health service delivery
What is Happening in General Practice?
• Demands on clinical and practice staff are increasing?
• Patients expect and demand greater attention
• GPs are overworked/working to capacity
• Increased need for chronic care Mx• Increased need for preventative
health Mx• Diversifying primary care
What is Happening in General Practice? continued
• Practices need to be competitive• Compliance activities e.g.
accreditation, accounting, are increasing
• Medico-legal requirements are becoming exhausting
• Stronger financial management has become essential
How can change be managed?
• Practice Principals & staff need to be convinced of the need for change
• Introduce a change facilitator as the leader of the process - Project Driver
• Critically review practice operation• Set priorities for the change project• Have a plan• Identify possible barriers & Mx
strategies
Conceptualise Practice & move from immediate need to
outcomes focusAdv RN Competency Standard 1
What Do We Want To Achieve?What Are Our Clinical Objectives?
Reduce overall risk in the community & improve health outcomes:
• Decrease complications, morbidity, mortality
• Improved QOL• Use a comprehensive, well co-
ordinated systematic approach to health care to achieve these goals
• Build capacity & collaboration in our health team (Competency Standard 5 integrates & evaluates knowledge & resources from different disciplines)
• Increase practice efficiency
• Adequately compensated for best health practice & improve pt outcomes
Run Cardiovascular Risk Clinic to:
• Identify an at risk group• Use evidenced based care to reduce
cardiac risk Conceptualise Practice & move from immediate need to outcomes focus, Adv RN Competency Standard 1
• Identify patterns & consequences of behaviours individual & group Anticipates need of individuals & groups with complex conditions +/- high risk, Adv RN Competency Standard 4
• Formulate action/care plan that will help to reduce risk & improve person’s health Manages outcomes in complex clinical situations Adv RN Competency Standard 3
• Outcomes based approach Uses health +/- nursing models to as basis for practice, Adv RN Competency Standard 2
EPC & the BEACH Program
• 1071 EPC reports• 598 Health Assess, (& 436 care Plans)• 60% female pts• New problems identified in 51 per 100 • New Px meds, advice for o/c 73 per 100• New Rx 29 per 100• New referrals 29 per 100• EPC Encounters in Australian Gen. Prac. ( AFP vol.35 Jan/Feb2006)
Strategy and Business plan
• No of visits? • How long each visit? • A treatment room?• What equipment is required? such as
ECG, Spirometry, scales, height measures
• Recall system?• Templates?• EPC, SIP, PIP, etc
The Business Case: Financial Models Resources
• http://www.gpnsw.com.au/programs/nursing-in-general-practice/nigpresources
• Health Assessments - (700, 702) • Healthy Kids Check (709 & 711)- Urban • Healthy Kids Check (709 & 711)- Rural• Immunisation (10993) - Urban • Immunisation (10993) - Rural• Cervical Screening (10994, 10995, 10998, 10999) – Urban • Cervical Screening (10994, 10995, 10998, 10999) – Rural • Wound Management (10996) – Urban • Wound Management (10996) – Rural • Practice Nurse Chronic Disease (10997) – Urban • Practice Nurse Chronic Disease (10997) – Rural • PN Antenatal Care (16400) – Rural only
Where do we begin?Set Up a System
• Identify target groups e.g. Cardiovascular disease, Diabetes, Asthma
• Decide on the type of tool you will use for your assessment
• Physical assessment• Needs Assessment• Follow up
Identify Your Target Audience!
Software can be used for patient searches and to generate lists based on criteria e.g.: •Diagnosis•time intervals •By Doctor•existing registers,e.g. Diabetes, cardiovascular•Medication
How to do a Database Search in Med Director
1. Tools2. Search database3. Age group (select range, M or F)4. (can be used for specific Dx or Rx)5. Search6. Should bring up printable list of patients7. Can be used to mail merge/print letter to
entire patient list
Keep your database clean & fast
Found your target Audience?The Referral Process
• Opportunistic i.e. when the pt visit’s the practice
• Letter to advise patients of your exciting new health initiative & invite them to participate
• Notice in waiting room & printed info
• Assistance from computer database (edit lists before mail merge & mail out)
• Remember the whole of team approach
Tips for Contacting Patients and Making Appointments• If possible phone patients
• Mention that you are calling on behalf of the surgery, and briefly explain why you are inviting them to attend the clinic (it helps to write a script for this!)
• Invite them to talk to the nurse or GP about the service
• Allocate appointment during the phone call (where possible)
• Coordinated with practice team to determine appropriate length for visit (e.g. 30 minutes) & flow on to doctor prn.
• Have appointment confirmation letters printed and fill in the appointment time and patient name
• +/- Reminder call week before the clinic date
Know Your MBS & Don’t be Afraid to Use It!!!!
• Know your billing• What are the health check & CDM
numbers?• How can I optimize care & get paid
correctly?• Is the patient eligible for flow on
services?• When should I add 10997?• Does this service qualify for PIP or
SIP funding?
Clinic ChecklistPre-clinic Generate a patient list Coordinate day/schedule with relevant clinic staff Contact patients Book appointments Confirm appointments (clerical support)
Clinic day Conduct assessments Make follow-up appointment if necessary Note down any further assessments that are needed
Post clinic Conduct post clinic discussion with the GP
Why use a specific tool?
• Specific Problems Need Specific tools
• Systematic approach to assessment • Preset, predictable amount of
information from each patient• Flexibility to document
additional information following pt cues
• Compatible with clinical software
Currently Available
• Clinical software inbuilt assessments /care plan
• Dept Health & Ageing
• Division downloadable templates
• RACGP paper care plan
• Make your own
Ensure You Have…
Medical equipment: appropriate space/room sphygmomanometer, stethoscope scales, BMI calculator, tape measure monofilament and blue sheet (foot assessment/diabetic
patients) urinalysis equipment disposable rubber gloves tissues
Paperwork: checklists/GP Management Plan/Assessment Form final appointment list patient files (including any existing GP Management
Plan and/or TCA if applicable) patient resource materials
CDM Clinic – Practice Nurse Role
• Family history (code prn)• Symptom/illness update• Social & lifestyle assessment & capacity
to absorb and change behaviour• Physical assessment, BP, BSL, eye chart,
weight, height, foot check, ECG• Identifies areas of need & Collect
information to support GP reviews of a care plan (CDM 10997)1
• Make recommendations e.g. GPMP, TCA HMR, allied health referral
CDM Clinic – Practice Nurse Role• Check a patient’s clinical progress1 • Provide self-management advice and
educational materials1,2
• Monitor medication compliance1
• Collect information to support Medicare Health Check Assessments (e.g. Item 717)2
• Communicates to pt’s GP • Integrates knowledge & evidence, evaluate from
a range of sources/ disciplines to improve health outcomes Adv RN Competency Standard 5 & 6, Act as advocate
• Notes MBS item numbers or bills where appropriate 1. Australian Government Department of Health and Ageing. MBS item 10997 for the provision of monitoring
and support to people with a chronic disease by a practice nurse or registered Aboriginal Health Worker on behalf of a GP. July 2007. Available at: http://www.health.gov.au (Accessed April 2008).
2. Australian Government Department of Health and Ageing. Medicare 45 year old health check. MBS Item 717. Available at: http://www.health.gov.au (Accessed April 2008).
Follow-up with the GP
• Arrange to meet with the relevant GPs at the end of the day to review paperwork together
• Make any recommendations you have regarding follow-up, referrals, pathology, medication reviews
• Completed paperwork should be filed in the patient’s notes or scanned in computer file
GP role in Nurse-led Clinic
• Completes physical assessment prn (heart, chest skin etc)
• Reviews current management• Reviews needs assessment
conducted by nurse• Ix and referrals prn • Approves follow up • Care plan discussion & consent –
refers back to the nurse• Billing: check all MBS items
included for consult
Flow on Services from Clinic• Care Plan: GPMP 721, TCA 723
• HMR Item 900
• Specialist referrals prn
• Allied Health Referrals
• Pt recall for ongoing disease surveillance
• Recall for next health check• ECG, Spiro
ITEM ITEM MBS NUMBER
MEDICARE REBATE
RECOMMENDED FREQUENCY
Preparation of aGP Management Plan(GPMP)
721 $133.65 2 yearly*Minimum claiming period - 12 months
Review of aGP Management Plan
725 $66.80 6 monthly
*Minimum claiming period - 3 months
Coordination ofTeam Care Arrangements (TCA)
723 $105.90 2 yearly
*Minimum claiming period - 12 months
Coordination of a Review of Team Care Arrangements
727 $66.80 6 monthly
*Minimum claiming period - 3 months
Nurse Item 10997 for CDM
• 5 visits to PN per year for pts with GPMP +/- TCA
• Ongoing monitoring & or health advice as part of care plan
• Data collection for care plans, diabetes cycle, asthma
Recall for Pt Review or Care Plan
• Add pt to recall database or log book• Book return visit to discuss changes
& medical review• Change GPMP at that visit prn & bill
725• Contact TCA participants for report
prn• Review amend &bill 727 TCA• Use Nurse item 10997 for CDM Mx
5/ year ($11.35)
• Discuss care plans & content & templates
Recall Letter
• Software templates (where possible)• It’s important to state:
– the reason/objectives of the visit– the date of the appointment– what the patient needs to bring (medications, vitamins,
complimentary meds & OTC)– proper attire (e.g. easy to remove shoes if conducting
foot assessments, ECG)– what may happen next (e.g. any follow up, pathology,
etc)– and a phone number to confirm appointments
Why do we Bother? The Upside
• A focused practice• Empowered staff by predictability of
the clinic • Enhanced ability to deliver improved
medical outcomes• Increased competitiveness• Greater involvement of practice staff
in clinical outcomes• Patient appreciation and retention
Summary
Capitalize on the clinical expertise of the nurse to:
• Expand/grow practice services• Enables practices to offer first class, best practice
preventative health & CDM services to their pts• Provides an excellent opportunity to follow up on
patients who might otherwise ‘fall through the cracks’
• Utilize Information Technology to simplify / streamline the process (refresh/clean databases)
• GP and practice nurse to define the level of monitoring and support provide by PN to patients
• The GP must be contactable to provide advice to the nurse if needed
How can I help my Nurse
Support through: • Encourage membership of APNA,
the professional association supporting primary healthcare nurses
• Education & courses to up-skill• Workshop & conference attendance• Division workshop & networking
meetings• In house training
APNA Online LearningUp-skill with APNA via their website’s online
course modules:• Diabetes Management in the General Care
Setting • Mental Health Part One - free • Mental Health Part Two - free • Smoking Cessation - free • Ulceration of the Lower Legs • Organ and Tissue Donation - free • National Bowel Cancer Screening Program- New • Understanding the MBS Items • IT skills including the Microsoft products • Business skills including writing business plans • Plus a whole lot more.
Resources for Preventative Health Checks
& ClinicsItems found at www.racgp.org.au:• Putting prevention into practice: guidelines for
the implementation of prevention in the general practice setting, 2nd edition(green book)
• Guidelines for preventive activities in general practice 6th edition (red book)
• The Snap Guidelines• Medical care of older persons in residential
aged care facilities (silver book)• National guide to a preventive assessment in
Aboriginal and Torres Strait Islander peoples
Resources• Whitehorse Division of General Practice, Nurse led clinics:http://www.centraltas.co.nz/LinkClick.aspx?fileticket=BoFvjc1nli8%3D&tabid=68&mid=378
http://www.gpnsw.com.au/programs/nursing-in-general-practice
http://www.3lp.rcna.org.au
http://www.apna.asn.au/associations/6694/files/6rolesofthegeneralpracticenurse.pdf
Melbourne East GP Network :http://www.megpn.com.au/Docs/ChronicIllness/ChronicIllness/NurseLedFINAL.pdf