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Using Nurse Led Clinics
A Team Approach to Managing Preventative
Health & Chronic Disease Care in General Practice
Karen Booth RN
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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
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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
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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
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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
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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
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• 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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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Currently Available
• Clinical software inbuilt assessments /care plan
• Dept Health & Ageing
• Division downloadable templates
• RACGP paper care plan
• Make your own
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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
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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
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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).
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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
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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
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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
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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
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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
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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)
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• Discuss care plans & content & templates
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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
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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
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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
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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
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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.
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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
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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
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