1. Using Nurse Led Clinics
A Team Approach to Managing
Preventative Health & Chronic
Disease Care in General Practice
Karen Booth RN

3. 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

4. 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

5. 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

7. 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

10. 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

11. • 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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. How to do a Database Search in Med Director
1. Tools
2. Search database
3. Age group (select range, M or F)
4. (can be used for specific Dx or Rx)
5. Search
6. Should bring up printable list of patients
7. Can be used to mail merge/print letter to entire patient
list
Keep your database clean & fast

19. 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

20. 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

21. 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?

22. Clinic Checklist
Pre-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

23. 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

24. Currently Available
• Clinical software inbuilt assessments /care plan
• Dept Health & Ageing
• Division downloadable templates
• RACGP paper care plan
• Make your own

26. 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

27. 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

28. 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).

29. 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

30. 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

31. 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

32. ITEM ITEM MBS MEDICARE RECOMMENDED
NUMBER REBATE FREQUENCY
Preparation of a 721 $133.65 2 yearly
GP Management Plan *Minimum claiming
(GPMP) period - 12 months
Review of a 725 $66.80 6 monthly
GP Management Plan
*Minimum claiming
period - 3 months
Coordination of 723 $105.90 2 yearly
Team Care
Arrangements (TCA) *Minimum claiming
period - 12 months
Coordination of a 727 $66.80 6 monthly
Review of Team Care
Arrangements *Minimum claiming
period - 3 months

33. 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

34. 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)

35. • Discuss care plans & content & templates

36. 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

37. 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

38. 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

39. 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

40. APNA Online Learning
Up-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.

41. Resources for Preventative Health Checks
& Clinics
Items 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

42. 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/6rolesofthegeneralpracticenurs
e.pdf
Melbourne East GP Network :
http://www.megpn.com.au/Docs/ChronicIllness/ChronicIllness/NurseLedFIN
AL.pdf