We can’t talk about chronic disease management without talking about the brave new world of Nurse led clinicsOver the evening we will cover the main points that you will need to help your practice set up these nurse led clinicsHopefully what you will take home is a template or system that you will be able you adapt to your personal clinic & pt needs & that you can also rework to suit different types of clinics.
Pts are more demanding both in that they have higher need due to more chronic illness, less time & support from hospital care, early discharge GP carrying the burden of post hospital carePts are more “consumer aware” & health care as a service/commodity pts aware of types care available & new Medicare rebates form many CDM & preventative health services
This is the dawn of a new era in health careWe have GP’s like nurses are an ageing workforce, decreasing in FTE numbers, increasing part-time work with the feminisation of general practiceMany GP already working to capacityHow long does it you to get to see your own GPWE have great new programs but how is general practice going to grow?NursesNursing related care is the one fastest growing areas of general practiceIn many practice it is the only way that GPs extend the type of services they offer to their community
WE can’t just rush in set up clinic & new project without considering important steps that we need for change to occurLook at positives & negatives.
Whole of team approachPatientClericalNurse GP
Gather & evaluate evidence from a range of sourcesIdentify patterns of response in individuals & groups adaptive & maladaptive health behaviours (Betty Anderson Model of Health Behaviours)Look at consequence of health & behaviour on individuals & groups.Undertake a systematic surveillance that will detect changes, relevant health related behaviours & use those assessment to formulate care & aide decision making with view it improving out pts health & reducing riskUsing an outcomes basis for our cardiac clinic
WE will refer to thses in depth in a later session today, but I make reference here because you need to have some idea of how your practice can afford to run a clinic.
The CDM program was introduced in 1998 by the Commonwealth GovernmentProvides preventive care for older Australians and improves the coordination of care for eligible patients with chronic conditions and complex care needsCDM clinics are appropriate for patients with chronic illnesses including CV diseases, asthma, diabetes, stroke, cancer, and musculoskeletal conditions
Staff can check previous billing Hx for SIP services, eligible gpmp & 10997Cardiac Screen & check up does not have a specific item number or SIP in the same way that diabetes assessments or age related health assessments doSo Depending on your pts age group you may be able to meet the Medicare criteria for billing some of those other items
Now we are ready to begin our nurse led clinic
Encourage membership of professional organizations such as APNA
We all want the best health outcomes for our patients well being. We are all the same team pulling together!!
Advanced practice nurse led clinics March 2010
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 focus Adv 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
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 Director1. 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 listKeep 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 neededPost 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 tissuesPaperwork: 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 appropriate1. 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 MEDICARE RECOMMENDED NUMBER REBATE FREQUENCYPreparation of a 721 $133.65 2 yearlyGP Management Plan *Minimum claiming(GPMP) period - 12 monthsReview of a 725 $66.80 6 monthlyGP Management Plan *Minimum claiming period - 3 monthsCoordination of 723 $105.90 2 yearlyTeam CareArrangements (TCA) *Minimum claiming period - 12 monthsCoordination of a 727 $66.80 6 monthlyReview of Team CareArrangements *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)
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
SummaryCapitalize 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 NurseSupport 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=378http://www.gpnsw.com.au/programs/nursing-in-general-practicehttp://www.3lp.rcna.org.auhttp://www.apna.asn.au/associations/6694/files/6rolesofthegeneralpracticenurs e.pdfMelbourne East GP Network :http://www.megpn.com.au/Docs/ChronicIllness/ChronicIllness/NurseLedFIN AL.pdf