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 [email protected]
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