nursing in your family practice initiative: primary health care – capital district health...

Nursing in Your Family Practice Initiative: Primary Health Care – Capital District Health Authority, NS

2009 NANB Annual General MeetingFredricton, June, 2009

Patsy Smith MN, RN Consultant on behalf of Primary Health Care, CDHA

The Challenge

Growing chronic care needs Access to care Health promotion & disease prevention Isolation Communication Coordination Public demand

The Capital Health Program

A program of supports for family physicians and family practice nurses working in fee for service practices in Nova Scotia

Funded by Primary Health Care, Capital Health with support from industry partners

Launched in March, 2007 4 program intakes (Last: 4th April, 2009) 41teams

The Model

Full scope of practice Highly integrated team environment Holistic approach (not focused on tasks) Health care encounters as opportunities (non-

selective patient visits) Patient fully participates in care System development to support application of

clinical practice guidelines Fee for Service

Nursing Integration

Healthy Living•Chronic disease

management•Disease Prevention•Health Promotion

Access•Access to care•Coordination

•Communication•Navigation

Team•Other health care providers

•Limiting risk•Building on strengths

Information

•More information•Better Decisions

Individual/Family/

Community

Chronic Diseases

Diabetes Hypertension Asthma/ COPD Cardiovascular Disease Cancer Mental Health Dyslipidemia Counselling Osteoarthritis

Health promotion and disease prevention

Risk factor assessment (e.g.metabolic syndrome) Well Baby Visits Well Women Visits Perinatal Immunizations Family History Healthy Eating Medication Management Physical Activity Screening (B/W, Mammograms, bone density,

cancer screening) Community Programming

Access and Coordination Multiple Specialists Communication (linking primary and

tertiary care) Complex Health Problems Long term care/ elderly care Follow-up Telephone Triage Other Care Providers (Public Health,

Community Groups, students)

liability

Canadian Nurses Protective Society Vicarious Liability Nurse works within scope of nursing practice

Business Case Fee for Service No “upfront” funding requirement Increase number of patient visits each hour (2-3) Physician must interact with patient in order to

bill Additional revenue generated covers expenses

associated with integrating a nurse

* Nurse must be working to full scope of practice and providing care for complex or time intensive patients.

Fee-for-service

Physicians are paid an established fee for visits.

Responsible for all overhead costs. Private business.

Bottom-line

Financially feasible Enhanced care Improved access Improved work life satisfaction

Program Elements

Physician resource manual and recruitment Nursing education program Resource kit Support for integration Collaborative team days Lecture series

Integration Support

Scheduling Office efficiency Space Organization Communication Full scope practice E-mail and phone support

Collaborative Team Development

Three team events: Diabetes, COPD, CV Network participating practices Primary Care providers as experts Focus on:

– Communication– Role clarification and collaboration in practice– Best practices– Clinical challenges – Electronic records

Lecture Series

Monthly education event Goals

• Networking• Continuing education• New physician engagement• Identification of issues• Information sharing

Program Evaluation (phase 1)Components

Provider Survey Service description survey Project tracking form Team survey

Program Evaluation (phase 1)

Key Outcomes:

Significantly enhanced access Nurses practicing in expanded scope Provider satisfaction Enhanced screening and prevention

Age Demographics by Patient (n=837)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

0 to 17 18 to 24 25 to 39 40 to 49 50 to 64 65 and Over Unknown

*

*Please note the Y-axis goes to 50%

n=106

n=39

n=108n=87

n=195

n=244

n=58

Patient Age Demographics

Type of Patient Care Demographics

Chronic Care Categories (n=473*)

0.0%10.0%20.0%30.0%40.0%50.0%

60.0%70.0%80.0%90.0%

100.0%

n=325

n=89 n=71n=134

n=61 n=55 n=51

n=21

*Please note patients could receiv e multiple types of care

Categories of Chronic Care

Total Services Provided (n=4,578)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Counselling/Education Vitals Medication Assessment Referrals Immunization Treatment

n=1111

n=600n=683

n=355 n=256n=232

*

* Please note the Y-axis only goes to 50%

n=1341

Types of Services Provided

Access• Practices accepting new patients

Pre: 20% indicated yes Post: 70% indicated yes

• Impact on wait times to book a regular appointment

70% indicated wait times have decreased 30% indicated wait times remain the same

• Absorbed patients from a practice who is downsizing or closing

60% indicated yes

Patients/hour

On average, practices were able to schedule approx. 2 additional patients each hour – This translates to an increase in capacity of ~ 40%

Able to accommodate more urgent care patients

Reduces wait times for appointments Should reduce ER visits and walk-in visits

Increasing Capacity

Diabetes education and insulin starts Procedures: 24 hour BP monitoring, ABI,

minor procedures, IUDs, cervical screening. Coordinating “specialist” visits Advancing the threshold for patient referral Electronic records Research Student mentorship

Decreasing Demand

Health promotion, screening and immunization Risk factors (Smoking, nutrition, activity,

stress, sexual health) Early detection and intervention (HTN, DM2,

COPD, Cardiac disease) Aggressive chronic disease management

(achieving targets, action plans, CPG) Education and enhancing self management

skills

Facilitating Referral

Decreased wait time to see family practice team

More timely referral Increased awareness of community resources

and how to access Enhanced information to assist in triaging

referrals

I believe patient care has improved, more services can be offered on-site and I am more content with my job.

(Physician Survey Response)

It really has enhanced the quality of care to my patients overall. The establishment of this new

collaborative approach after 17 years of solo general practice is

quite an achievement in itself and this to the credit of the program.

(Physician Survey Response)

Benefits

Enhanced care Improved access Improved work-life situation Team approach Increased capacity

Program Evaluation (phase 2)

Spring, 2009

Chart audit Patient satisfaction survey

Integration support is key!

Mentorship Practice support Networking with peers Ongoing education Specific to primary care context (providers as

experts!)

Developed in consultation with…

Doctor’s Nova Scotia College of Registered Nurses of Nova Scotia NS Medical Services Insurance program Department of Health Section of Primary Health Care CDHA IWK Community Health Board Provincial Programs Physicians and Family Practice Nurses (locally and nationally) Dalhousie University School of Nursing

Thank-you

Shannon Ryan, Manager PHC, Principal investigator shannon.ryan@cdha.nshealth.ca

Lynn Edwards, Director PHC Lisa Blackwood, Project Manager, PHC Stephanie Health, Research Power Inc. Dr. Jeffrey Colp, Family Physician RN professional development centre Primary health care team, Capital Health