Integrated Chronic Disease Nurse Practitioner Service REPORT... · practitioner (ICDNP) clinic for improving patient outcomes and decreasing health service utilisation, as well as

EVALUATION FINAL REPORT

Integrated Chronic Disease Nurse Practitioner Service

Principal InvestigatorsProfessor Ann Bonner – School of Nursing, Queensland University of TechnologyDr Clint Douglas – School of Nursing, Queensland University of Technology

Nurse PractitionersMrs Jennifer Abel – Logan HospitalMs Maureen Barnes – Logan HospitalMs Cassandra Stone – Logan HospitalMs Justine Heatherington (NP candidate) – Logan Hospital

Research AssistantsMs Kathryn Havas – School of Nursing, Queensland University of TechnologyMs Nazli Ghafouryan Gomish Bashi – School of Nursing, Queensland University of Technology

Report Date: July, 2015

Recommended Citation Bonner, A., Douglas, C., Abel, J., Barnes, M., Stone, C., Heatherington, J., Havas, K., Bashi, N. (2015). Integrated chronic disease nurse practitioner service evaluation report. Brisbane, Queensland: Queensland University of Technology.

TABLE OF CONTENTSExecutive summary .................................................................................................................. 2

Background .............................................................................................................................. 3

EvaluationFramework............................................................................................................ 4

Evaluation Aims & Objectives .................................................................................................. 5

Methods .................................................................................................................................... 5

Approvals.................................................................................................................................. 6

Evaluation Findings .................................................................................................................. 6

Structure................................................................................................................................... 6

Costs......................................................................................................................................... 6

Process..................................................................................................................................... 7

›Appointments.................................................................................................................... 8

›WaitTimes&DNARates.................................................................................................. 8

Outcomes .................................................................................................................................. 9

›Clinical&DemographicInformation.............................................................................. 9

EmergencyDepartmentPresentations,HospitalAdmissions,andHospitalintheHomeuse................................................................................................10

PatientAchievementofClinicalTargets...............................................................................11

Patient-ReportedOutcomeMeasures..................................................................................11

›OverallSampleInformationforPatient-ReportedOutcome

›Measures..........................................................................................................................11

›Disease-SpecificKnowledge..........................................................................................12

›Self-CareBehaviour........................................................................................................13

›ChronicDiseaseSelf-Efficacy........................................................................................14

›Health-RelatedQualityofLife.........................................................................................14

›SatisfactionwithClinic....................................................................................................15

›HealthServiceUtilisation................................................................................................15

QualitativeInterviewsandFocusGroups.............................................................................16

›PatientInterviews............................................................................................................16

›StakeholderFocusGroups..............................................................................................17

Conclusions & Recommendations ..........................................................................................19

References .............................................................................................................................. 20

2 Integrated Chronic Disease Nurse Practitioner Service

Executive SummaryQueenslandUniversityofTechnology(QUT)wascontractedtoconductanevaluationofanintegratedchronicdiseasenursepractitionerserviceconductedatMeadowbrookPrimaryCarePractice.Thisevaluationisacollaborativeprojectwithnursepractitioners(NP)fromLoganHospital.

Theintegratedchronicdiseasenursepractitionerserviceisanoutpatientclinicforpatientswithtwoormorechronicdiseases,includingchronickidneydisease(CKD),heartfailure(HF),diabetes(typeIorII).Thisdocumentreportsonthefirst12monthsoftheservice(4thJune,2014to25thMay,2015).

Duringthisperiod:

• 55patientsattendedtheNPclinicwith278occasionsofserviceprovided

• Almostall(95.7%)patientsattendedtheirscheduledappointments(only4.3%didnotattendanappointment)

• SinceattendingtheNPclinic,themajorityofpatients(77.6%)hadnoemergencydepartmentvisitsrelatedtotheirchronicdisease;only3requiredhospitaladmission.

• 3patientsundertheserviceweremanagedwithHospitalIntheHomewhichavoidedmorethan25hospitalbeddays

• 41patientsconsentedtojoinaprospectivecohortstudyofpatient-reportedoutcomesandpatientsatisfaction

• 14patientinterviewsand3stakeholderfocusgroupswerealsoconductedtoprovidefeedbackontheirperceptionsoftheNP-ledserviceinnovation

Thereportconcludeswithsevenrecommendations.

Integrated Chronic Disease Nurse Practitioner Service 3

Figure 1.RelationshipbetweenCVD,diabetes,andCKD.FromAustralianInstituteofWelfare(2015c).

CVD

Disturbed mineral metabolism

AnaemiaShared risk factors

AtherosclerosisHypertension

Shared risk factors

Diabetes

CKD

HypertensionShared risk factors

HypertensionShared risk factors

Shared risk factors

High blood glucose-related kidney damage

Shared risk factors

BackgroundChronicdiseaserepresentsthebiggesthealthchallengethatAustraliafaces–challengingustotransformthewayhealthcareisdelivered.Thegrowingpersonal,socialandeconomicburdenofchronicdiseaseunderscorestheneedforchange.In2011-12,20%oftheAustralianadultpopulationreportedadiagnosisofcardiovasculardisease(CVD),5%diabetesand10%hadmarkersofchronickidneydisease(CKD;AustralianInstituteofHealthandWelfare[AIHW],2015c).In2011,69,000adultshadanacutecoronaryevent,andover53,500beganusinginsulintotreatdiabetes.In2010,therewereover4,800newcasesofend-stagekidneydisease(ESKD;AIHW,2015c).Together,CVD,diabetes,andCKDaccountedforapproximately1.8millionhospitalisations,20%ofallAustralianhospitalisationsbetween2012-13(AIHW,2015a).Furthermore,in2011,oneormoreofthesediseaseswasanunderlyingorassociatedcausein61%ofalldeaths(AIHW,2015b).

Althoughtraditionallymanagedindividually,CVD,diabetesandCKDareinterrelatedandcommonlyoccurtogether.Figure1showsthecommonbehaviouralandbiomedicalriskfactorsfortheseconditions.Thiscombinationofchronicdiseaseaddscomplexitytomanagementandcanleadtoworseoutcomesforpatients(AIHW,2015a,2015c).In2011-12,7%oftheadultAustralianpopulationhadtwooftheseconditions,and1%hadallthree.Overtwo-thirdsofpeoplewithdiabetesalsohadCVDand/orCKD(AIHW,2015c).Thesimilarcausesandtreatmentsforthesechronicdiseasesmeanthatthereisgreatpotentialforintegratedmodelsofcare(AIHW,2015c).Ithasalsobeensuggestedthatimprovedaccesstoprimaryhealthcarehasthepotentialtoreducehealthserviceutilisationandimproveoutcomesforpatients(AIHW,2015a).


Chronicdiseasemanagementistypicallyamedicalspecialistledextensionofacutemanagementofteninhospitaloutpatientclinics.Thereareoftenlongwaitingtimesforaclinicappointment,leadingtolatestagepresentation,worseningofsymptoms,increasingcomplications,andfragmentationofhealthcareparticularlyforthosewithmultiplechronicdiseases.

InAustraliathereareseveralnursepractitioner(NP)clinicsforpatientswithchronicdisease.NPsholdaMasterslevelqualificationandareauthorisedtopracticeautonomously,orderandinterpretdiagnosticinvestigations,makereferralstootherclinicians,andprescribemedications.NPclinicsare,however,alsotypicallystructuredalongdiseasesiloeslikemedicalclinics,whichisproblematicforpeoplewithmultipleconcurrentchronicdiseases.

InJune2014,followingfundingfromtheOfficeoftheChiefNurseandMidwiferyOfficer,anovelcommunity-basedintegratedNPcliniccommencedforpatientswithatleasttwochronicdiseasesincludingCKD,diabetesorHF.Thepurposeofthisreportistoevaluatethefirst

12monthsoftheintegratedchronicdiseaseNPcliniclocatednearLoganHospitalcampusataGPSuperclinic(Meadowbrook).TheclinicisstaffedbythreeNPs,oneNPcandidateandanAdministrationOfficer.

Evaluation FrameworkTheDonabedianQualityFrameworkforevaluatinghealthservicesisanapproachtoreportingaboutthequalityofhealthcare(seeFigure2).Theframeworkcomprisesthreedimensions:

1. Structure-referstotheattributesofthehealthcaresetting(material,humanandorganisationalresources);

2. Process -referstowhatisactuallydoneinthegivingandreceivingofhealthcare;and

3. Outcome-referstotheeffectsofhealthcareonpatients

Thevalueofthisframeworkisthatitsupportsasystematicevaluationofhealthcareservicesatthelevelofthepatient/providerinteraction.

Figure 2.Donabedianframeworkforevaluatinghealthservices(Donabedian,1988)

Process elements

• Treatment process• Stages of treatment• Appropriateness• Service process

Outcomes

• Death• Adverse events• Readmissions to hospital• Resource use• Patient satisfaction• Quality of life

Structural elements

• Characteristics of:• Community • Institution• Provider• Patient


Evaluation Aims and ObjectivesTheaimofthisevaluationwastodeterminetheeffectivenessoftheintegratedchronicdiseasenursepractitioner(ICDNP)clinicforimprovingpatientoutcomesanddecreasinghealthserviceutilisation,aswellastoinvestigatepatientandhealthproviderperceptionsofthisNP-ledserviceinnovation.Theevaluationperiodwasthefirst12monthsoftheICNPclinic(4June,2014until27May,2015).

Thespecificobjectivesweretodetermine:

1. WhatarethedemographicandclinicalcharacteristicsofpatientswhoattendtheICDNPclinic?

2. WhatproportionofpatientswhoattendtheICDNPclinicachievenationallyrecognisedclinicaltargets(e.g.levelsofbloodpressure,HbA1c,cholesterol)?

3. Whatarethelevelsofpatient-reported:

a.Disease-specificknowledge

b.Abilitytoself-care

c.Chronicdiseaseself-efficacy

d.Qualityoflife

e.SatisfactionwiththeserviceprovidedattheICDNPclinic

4. Isthereanimprovementinthefollowingpatient-reportedoutcomesat6and12months:

a.Disease-specificknowledge

b.Abilitytoself-care

c.Chronicdiseaseself-efficacy

d.Qualityoflife

e.SatisfactionwiththeNPMOCservice

5. Whatproportionofpatientspresenttotheemergencydepartmentforexacerbationofchronicdisease?

6. WhathospitaladmissionsoccurforexacerbationofchronicdiseasewithinthecohortattendingtheICDNPclinic?Whatistheaveragelengthofstay?

7. WhatisthewaitingtimeforanappointmentintheICDNPclinic?

8. Whatarethe‘didnotattend’ratesintheICDNPclinic?

9. WhatisthenumberandpatternofreferralsmadebynursepractitionersattheICDNPclinic?

10.WhatarethepatientandhealthcarestakeholderperceptionsoftheICDNPclinic?

Methods Alongitudinal,prospective,cohortstudywasundertakentoexaminetheimpactoftheNPserviceonpatientoutcomes.

ClinicaltargetswereprovidedbytheNPs:

• CKD–bloodpressure,cholesterol,andalbumin:creatinineratio(ACR)orprotein:creatinineratio(PCR)

• Diabetes–HbA1c,bloodpressureandcholesterol

• HF–noclinicaltargets

Allpatientswhoattendedtheclinic,spokeEnglish,andwerecognitivelyintacttocompletepatient-reportedoutcomemeasureswereeligibletoberecruitedtothestudy.Thosewhoconsentedcompletedabatteryofstudymeasures,aspresentedinTable1.

OutcomePrimary Diagnosis

CKD* DM* HF*

Disease-specific knowledge Knowledge in Kidney Disease Survey (KiKS)

Diabetes Knowledge Questionnaire (DKQ)

Dutch Heart Failure Knowledge Scale (DHFKS)

Ability to self-care Chronic Kidney Disease Self-Management Instrument (CKD-SM)

Summary of Diabetes Self-Care Activities (SDSCA)

Self-Care of Heart Failure Index (SCHFI)

Chronic disease self-efficacy Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEMCD-6)

Quality of life 36-Item Short Form Health Survey (SF36)

Satisfaction with the ICDNP clinic

Patient Satisfaction with Nurse Practitioner Care for Presenting Problem (from AUSPRAC NP Toolkit)

Health service utilisation Patient’s Level of Healthcare Service Utilisation (from AUSPRAC NP Toolkit)

*Chronickidneydisease(CKD),Diabetesmellitus(DM)andHeartFailure(HF)

Table 1.Patient-reportedoutcomemeasuresusedtoassessoutcomes,byprimarydiagnosis


Thesemeasureswerecompletedatthebeginningoftheproject(T0),andaretobecompletedagainsix(T1)and12(T2)monthsfrombaselinecompletioninordertoassesschange.Attimeofreportpreparation,41patientshadcompletedT0assessment,14hadcompletedT1,andnonehadreachedT2.DuetothesmallnumberofparticipantswhohadcompletedT1assessmentattimeofwriting,analysisofchangeinpatient-reportedoutcomesovertimewasnotpossible.

QualitativeinterviewswithpatientsandfocusgroupswithstakeholderswereconductedinordertoassesspatientandstakeholderperceptionsoftheICDNPclinic.

Clinical,demographic,andhealthutilisationdatawasaccessedforallparticipantsattendingtheclinic,whetherornottheyparticipatedinquestionnairecompletionand/orinterviews.

ApprovalsAllrequiredethicalandresearchapprovalswereobtainedbeforerecruitmentanddatacollection.PrincessAlexandraHospitalprovidedhumanethicsapproval(HREC/14/QPAH/313).Publichealthauthorityprovidedapproval(RD005339)tocollectde-identifieddatafrompatients’hospitalrecords.QueenslandUniversityofTechnologyprovidedhumanadministrativereviewapproval(1400000633).LoganHospitalprovidedresearchgovernanceapproval(SSA/14/QPAH/329).

Evaluation FindingsStructureTheICDNPclinicisastructured,community-basedchronicdiseasemodelofcaredeliveringcoordinatedservicestochronicdiseasepatientswithmultiplecomorbiditiesinahigh-riskpopulationgroup.Theclinicisconductedonceaweekoff-site(onWednesday)ataGPpractice.Thereiseasyparkingaccessforpatients.

ForthefirsttimeinQueensland,NPsacrossmultiplespecialties(renal,cardiac,anddiabetes)arecollaboratingtoprovidecomprehensivechronicdiseaseservices.

ThreeNPs(onefromeachspecialty)andanNPcandidatehaveseenpatientsattheICDNPclinicduringtheevaluationperiod.Insteadofchronicdiseasecarebeingprovidedinindependentspecialtystreams,comprehensivecareisdeliveredinanintegratedapproach.

Thegoalsareto:

• Ensuretimelyreferralandsymptommanagement

• Reducepresentationsforoutpatientclinics

• Provideaholisticmanagementapproachtochronicdisease

• Provideearlydetectionandintervention

• Reducehospitalpresentationsandadmissions

• Developasustainableworkforcemodel

• Strengthenservicesacrossthecontinuum

• Deliverapatient-centricmodelinamoreappropriatesetting.

The Model and Set up (Structure) Duringfocusgroupswithkeystakeholders,theNP

clinicasamodelwasidentifiedbyhealthcareprofessionalsas“goldstandard”andhighlyinnovative,identifyingtheimportanceofitsfutureapplicationstate-widetoreachpatientsinremote

andruralsettings.Healthcareprofessionalsstronglybelievethatpatientoutcomesintheaforementioned

settingswouldbeenhancedifNPclinicswereintroduced.Furthermore,extensionoftheclinictothehomesettingwashighlightedasimportantgiventheissuespatientsmay

befacedwithinthecommunity.Healthcareprofessionalnumber3(HCP3)recommendedfundingbesoughttobridgetheNPclinicandhomecaretoenhancepatientcareandmanagement.Overall,themultidisciplinaryteamstronglybelieveinthismodelofserviceforthecareandmanagementofpatientswithchronicdisease.

CostsThreeNPsstafftheclinicforonedayperweek.ThecostofstaffingthecliniccanbeseeninTable2.

Table 2.StaffingcostsofICDNP

Number of NPs 3

Cost for three NPs per day (NRG 8.02) $1,630.42

Annual cost of three NPs for one day per week

$76,630.12*

*Detailsunavailabletoevaluationteamtocalculatecosts.Annualcostisunadjustedformissedclinicsduetoannualleave,sickleave,etc.OthercliniccostssuchasAdministrationOfficer,roomhire,equipment,etcnotincluded.

I’m coming here to get advice on my condition and help, which has been very forthcoming, very

enlightening I suppose, and helpful to my recovery [Patient]


I think I’d prefer to come to a nurse and ask her than the

Hospital. I don’t seem to get much answers at the hospital, yeah.

[Patient]

Thecostofanoccasionofservicevariesbyprimarydiagnosis,andcanbeseeninTable3.

Table 3.CostofappointmentatICDNPclinic

CKD @ $645 x 82 appointments $53,890

Diabetes @ $347 x 45 appointments $15,615

HF @ $263 x 124 appointments $32,612

TOTAL $102,117

ProcessPatientswerereferredbyspecialistmedicalpractitioners(renal,cardiac,orendocrine)atLoganHospitaltoeachNursePractitioner.Ifthepatienthadtwoorallthreechronicdiseases,theNursePractitionersthenreferredthepatienttotheICDNPclinic.TheNPsworkasateamtoprovidespecialisedcare,self-managementstrategiesandeducation.Figure3describestheprocessofreferraltotheICDNPclinic.

Duringtheevaluationperiod,therewere219appointmentsattheICDNPclinic.AbreakdownofthenumberofappointmentsforeachNPhadcanbeseeninTable4.Therewasamedianofthreeappointmentsperpatientwithsomepatients(mostlyHF)attendingtheclinicupto14timeseachduringthe12monthevaluationperiod.NotethatpatientsmayhaveseenmorethanoneNPduringoneappointment.

Table 4. NumberofappointmentsattendedbyeachNP

CKD NP 82

Diabetes NP 45

HF NP 124

NP Candidate 27

TOTAL 278

TheservicesofferedattheICDNPclinicinclude:

• Comprehensivepatientassessmentsandcareplanningdevelopedinconsultationwithpatientsand/orcarers,whichreflectrealisticgoalsandtimeframes

• Patienteducationbasedonaself-managementmodel

• Exercise/lifestyleprograms

• Medicationeducation,review,andconsultation

• Coordinatedapproachtohealthcareinvolvingthespecialtyteamsandthegeneralpractitioner

• Telephonefollow-upandreview

• Interfacewithmultidisciplinaryteamswhichincludemedical,nursing,andalliedhealthspecialists.

Figure 3.ProcessofPatientReferraltoICDNPClinic

Integrated Chronic Disease Nurse Practitioner MOC

As per approved NP MOC Practice

Scope


Scope


Scope

Case managed patient as per inclusion/exclusion critera—must have 2 out of 3 chronic disease

co-morbidities

Discharge back to GP

Remain with NP

Transfer to Specialist Medical

clinic

Discharge back to GP

Remain with NP

Team

Transfer to Individual NP clinic

Transfer to Specialist Medical

clinic

NP Nephrology

NP Diabetes

NP Heart Failure

NP Nephrology

NP Diabetes

NP Heart Failure

Usual Care Usual Care Usual Care Integrated Chronic Disease NP MOC

New Patient Referral to NP


Objectives 6 & 7: Waiting Times and “Did Not Attend” RatesTherewastimelyaccesstotheNPclinicoverall.WaitingtimefromreferraltoICDNPclinictofirstappointmentwas19.5daysonaverage.MedianwaittimesbyprimarydiagnosiscanbeseeninFigure4.

Figure 4.Waiting Time for First Appointment

Throughouttheevaluationperiod,therewere12instanceswherethepatientdidnotattendtheirappointment.Ofthe278scheduledappointments,only4.3%appointmentswereclassifiedas“didnotattend.”

Multidisciplinary Team: Communication and referral (Process)StakeholderfocusgroupsprovidedfurtherinsightintotheICDNPprocess:

• Referraltotheclinicisincreasing,withHCP1identifyingapproximately10-20patientshavingbeenreferredbyonespecialistalone.

• ReferralbetweenspecialistsandtheNPoccursviaemailorpostalmail,withcontinuingcorrespondencebetweenhealthcareprofessionalsfromtheclinic.Additionally,alliedhealthreferralattheclinicisidentifiedrecognisingthescreeningprocessoccurringattheNPcliniclevel.Forexample,thepodiatryteamhighlightedtheeffectivenessofthepre-screeningandreferralprocessofhighriskfeetattheNPclinic.Theteamidentifiedthepromptnessinreferraltotheirclinic,asopposedtothegeneralreferralprocess.

• Healthcareprofessionalsidentifiedtheefficiencyandeffectivenessincommunicationandreferralbetweenthemultidisciplinaryteamandtheclinic.

HealthcareprofessionalshighlightedhowtheefficientreferralprocessisalsoofbenefittothepatientasitremovestheneedtoseetheirGP,followedbyapotentialadmissiontoahospitalemergencydepartmentforreview,whichwouldmostlikelyleadtoeventualreferraltotheNPclinic.OnealliedhealthteammemberreinforcedhowmanagingpatientsattheNPclinicmaylimithospitalisationandfacilitatemanagementintheclinic‘community’.

HealthcareprofessionalsidentifiedinparticularthereductioninriskofpatientsrequiringlowerlimbordigitamputationbecauseofattendingtheNPclinic,highlightingtheimportanceandcontinuinginvolvementofalliedhealthcareprofessionalsasanintegralpartofNPclinics.

CommunicationandapotentialgapinthecurrenthealthcaresystembetweenGPs,hospitalsandoutpatientdepartmentswasidentifiedbyhealthcareprofessionals.Healthcareprofessionalsrecognisedpotentialinaccuraciesinpatients’medicationlistsalongwithpoormedicationcomplianceandadherence.TheroleofapharmacistintheNPclinicwasraisedtopotentiallybridgethegapandenhancecommunicationbetweenthemultidisciplinaryteam,andpatient.

Lastly,healthcareprofessionalsidentifiedtheimprovedcommunicationandlinksbetweentheGPsandtheclinic.HealthcareprofessionalshighlightedthatGPsappeartobemoreeffectivelymanagingthelowerriskrenalpatientsandasaresultreferringthoseinlaterstagesofCKDtotheNPclinicthatarerequiringreferral.Furthermore,alliedhealthteamidentifiedeaseofaccesstopatientcareplansthroughGPstherefore,demonstratingenhancementsincommunication.

Staff Member Opinion

So I’m very supportive of that clinic. I think it’s a good idea. The sorts of patients that I think will probably really benefit are those that have earlier chronic kidney disease; maybe Stages 1 through 3 quite stable with no proteinuria and who have lifestyle issues that need to be addressed and a lot of the patients who have diabetes and with their kidney disease; heart failure; heart problems too, so I think it’s a really useful clinic for those particular patients.

0

10

20

30

Median Wait Times (Days)

Median Wait Times (Days)

21

15

19

CKD Diabetes HF

Yes it’s always the same person you see and so they know you and

understand you. Whereas when you go to the hospital you never see the same person

twice so it must be difficult for them to have any continuity [Patient]


Outcomes Duringtheevaluationperiod,55patientsattendedtheclinic,ofwhom41wererecruitedintotheresearchproject.TherecruitmentanddatacollectionflowchartcanbeseeninFigure5.Demographicandclinicaldata,aswellasdataforemergencydepartment(ED)presentationsandadmissionstoLoganhospitalarereportedforallwhoattendedtheservice.

Withdrawn = 1 (HF)

Consented + completed T0 = 41

CKD = 19Diabetes = 5

HF = 17

Completed T1 = 14

CKD = 7Diabetes = 0

HF = 7

Ineligible = 5Refused = 2

Patients seen in clinic = 48

Patient Interviews = 14CKD = 8Diabetes = 0HF = 6

Stakeholder Focus Groups = 3Participant backgrounds:

• Podiatry• Nurse Unit Manager• Pharmacy• Medical specialist• Nurse Practitioner

Figure 5.Flowchart of recruitment and data collection

Objective 1: Clinical and Demographic Information

Duringtheone-yearperiod,patientsincluded37males(67.3%)and18females(32.7%),withameanageof66years(range:32to89years).ThemostcommonplaceofbirthwasAustralia(25patients;45.5%),followedbytheUKandtheSouthPacificIslands(eachninepatients,16.4%;seeFigure6).NoparticipantsidentifiedasIndigenous,andone(1.8%)identifiedasSouthSeaIslander.Themajorityofpatients(53;96.4%)spokeEnglishastheirmainlanguage.OtherlanguageswereSamoan(2%)andFinnish(2%).Most(39;70.9%)weremarriedordefacto(single[14%],ordivorced[15%]).

Australia New Zealand UK Europe South Pacific Islands Indonesia Russia Vietnam

CKD 47%

Diabetes 24%

HF 29%

Australia 45%

New Zealand 11%

UK 16%

Europe 6%

South Pacific Islands

16%

Indonesia 2%

Russia 2%

Vietnam 2%


CKD 47%

Diabetes 24%

HF 29%

Australia 45%

New Zealand 11%

UK 16%

Europe 6%


16%

Indonesia 2%

Russia 2%

Vietnam 2%

Place of Birth

Figure 6.Placeofbirth

Figure7summarisestheprimarydiagnosisallpatientsattendingtheICDNPclinic.26patients(47.3%)hadaprimarydiagnosisofCKD,13(23.6%)hadaprimarydiagnosisofdiabetes,and16(29.1%)hadaprimarydiagnosisofHF.83.0%ofpatientshadtwodiagnoses,and17.0%hadallthree.


CKD 47%

Diabetes 24%

HF 29%

Australia 45%

New Zealand 11%

UK 16%

Europe 6%


16%

Indonesia 2%

Russia 2%

Vietnam 2%

Primary Diagnosis

Figure 7. Primary diagnosis

It’s given me a lot better knowledge and yeah boosted my

confidence really well to deal with it, because I feel more connected with the health service so to

speak, because of it, you know what I mean, rather than just being a patient doctor relationship,

it’s more involved [Patient]


Smokingstatusinformationwasavailablefor31patients,andofthese67.7%(21)wereex-smokers,22.6%(7)werenon-smokers,and9.7%(3)werecurrentsmokers.

Figure8presentsbodymassindex(BMI)classifiedbyprimarydiagnosisandbyhealthyweight(BMI18.5-25kg/m2),overweight(BMI26-30kg/m2)andobese(BMI>30kg/m2).Noneofthe18CKDpatientsforwhomBMIdatawereavailablewerewithinthehealthyrangeof18.5-25.Three(16.7%)wereclassifiedasoverweight,andtheremaining15(82.7%)wereintheobeseranges.OnlyoneofthefivediabetespatientsforwhomBMIdatawereavailablehadaBMIwithinthehealthyrange.Oneparticipant’sBMIplacedthemintheoverweightrange,withtheremainingthreeintheobeseranges.BMIwasonlyavailableforthreepatientswithHF,andthesevaluesplacedallpatientsintheobeseranges.

BMI

CKD Diabetes HF

Healthy Weight Overweight Obese

0.0%

16.7%

82.7%

20.0% 20.0%

60.0%

0.0% 0.0%

100.0%100%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Figure 8.Body Mass Index by primary diagnosis

Objectives 5 & 6: Emergency Department Presentations, Hospital Admissions, and Hospital in the Home useOverthree-quartersofpatientsattendingtheNPclinic(38;77.6%)didnotpresenttotheEmergencyDepartment(ED)forchronicdiseaseexacerbationduringtheevaluationperiod(seeFigure9).AllofthosewhopresentedhadHF.Similarly,mostpatients(40;81.6%)werenotadmittedtoLoganHospitalforchronicdiseaseexacerbationduringthistime(seeFigure10).Ofthosewhowereadmittedtohospitalfordiseaseexacerbation,

allhadHFwhospentonedayasaninpatient(threepatients;37.5%;seeFigure

11).ThreepatientswithHFusedtheHospitalintheHome(HITH)service,oneforonedayandtwofortwodays.

0

5

10

15

20

25

30

35

40

Presentations to ED

0 1 2 3 4 5 6 7 8 9 10 11 12

Number of ED Presentations

38

4 3

2

1

0 0 0 0 0 0 0

1

Num

ber

of P

atie

nts

Figure 9.Presentations to Emergency Department

Nurse Practitioner Story – Hospital in the Home

Oh yeah, and using our hospital in the home team as well to help manage these patients because I can go out with them and they’ve done a lot of learning about the three different conditions too, through our patients from the clinic that they wouldn’t have had access to before, it would’ve always been just waiting for them to come into ED or be sitting in the ward and someone trying to get them out the door.

So quite a few of my patients that are deteriorating and I’m finding that using our clinic is great to see them regularly to keep them out of hospital and even though they come back and I know we’re still lengthening the time in between and that sort of thing and keeping them at home and the patients are so grateful because before they were just always in ED whereas now they’ve got more expert people involved instead of always a different doctor in ED or a different team in the hospital.

So it’s not like we own them but if you know what I mean, they’re our patients so we follow them to where, whatever’s going on. So I’m hoping there’ll be a good outcome from all the work we’re putting into this patient at the moment but if nothing else the nurses have asked for us to give direction for any patient who comes in who’s either renal or heart failure, fluid overloaded having hypos, so that’s just one example of how to better manage a critical situation when the protocol doesn’t fit.… with multi nurse

practitioner clinic what it is for our patients is it’s like a one

stop shop [Staff]


0

5

10

15

20

25

30

35

40

Number of Admissions to Logan Hospital

0 1 2 3 4 5 6 7 8

Admissions

40

3 3 1 1

0 0 0

1

Num

ber

of P

atie

nts

Figure 10.NumberofadmissionstoLoganHospital

0

1

2

3

Days Spent as Inpatient

1 2 3 4 … 9 … 12 … 39

Days

3

1

0

1

0

1

0

1

0

1

Num

ber

of P

atie

nts

Figure 11. Daysspentasinpatient

Objective 2: Patient Achievement of Clinical TargetsTheevaluationteamwasprovidedwithclinicaltargetsforCKDanddiabetes,andthesewereusedtoinvestigatehowmanyclinicpatientswereachievingthesetargets.ItwasreportedthattargetsforHFarenotusedforthesepatients.Duetoextremelylimitedfollow-updata(definedasdatafromsixmonthsorlongerfrompatients’entrytotheclinic),comparisonswerenotpossible.Baselinedataarereported,whereadequateresultsareavailable.

CKD

• Ofthe22CKDpatientsforwhombloodpressuredatawereavailable,81.8%(18)wereachievingthesystolicbloodpressuretargetof130mmHgorunder.95.5%(21)wereachievingthediastolicpressuretargetof80mmHgorunder.

• CholesteroldatawasavailableforninepatientswithCKD,three(33.3%)ofwhomwereachievingthetargetvalueof<4.0mmol/L.

• 25%(4)ofthe16CKDpatientswithACRorPCRdataavailablehadvaluesconsistentwithproteinuria,while12(75%)hadvalueswithinthenormalrange.

Diabetes

• BaselineHbA1cdatawereavailablefor10patientswithaprimarydiagnosisofdiabetes.Atentrytotheclinic,only20%ofpatientswereachievingtheclinicaltargetof<7%.

• Bloodpressuredatawereavailableforninepatientswithdiabetes,andthisrevealedthat77.8%wereachievingthesystolictargetof130orbelow,and66.7%(6patients)wereachievingthetargetdiastolicpressureof80orlower.

• Whilecholesterolresultswereavailableforonlyfivediabetespatients,noneofthesepatientswereachievingthetargetof<4.0mmol/L.

Patient-Reported Outcome Measures

Objective 1: Overall sample information for patient-reported outcome measuresAttimeofwriting,41participantshadcompletedbaseline(T0)assessment,ofwhom14hadcompletedT1.Mostparticipants(26,65.0%)hadaneducationlevelofgrade10orbelow(seeFigure12),andthemajority(25,61.0%)wereretired.Theannualhouseholdincomeofmostparticipants(25,61.0%)wasunder$40,000perannum(seeFigure13).

Level of Education

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No form

al (1)

<Grade 10 (1

3)

Grade 10 (1

2)

Grade 12

(3)

Tafe (9

)

Undergra

duate (2

)

Postgra

duate (0

)

Figure 12.Levelofeducation


0

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Level of Income

< $20,0

00 (12)

$20,000 -

$39,999 (1

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)

$100,000 -

$119,9

99 (1)

$120,0

00+ (1)

Don’t know/W

ould

rath

er not s

ay (13)

Figure 13.Levelofincome

Mostparticipants(26,63.4%)wereex-smokers.Onlyoneparticipantreportedrecreationaldruguse,andfiveparticipants(12.2%)fellintheclinicalrangefordrinkingbehaviour.Themajorityofparticipants(31,77.5%)hadseenanursepractitionerpriortoenteringtheclinic.

Objective 3a: Disease-specific KnowledgeChronic Kidney Disease: Knowledge in Kidney Disease Survey

Disease-specificknowledgeamongstthe19peoplewithaprimarydiagnosisofCKDwhocompletedT0assessmentwaslow.Participantsreceivedameanscoreof16.20outof28possiblepoints(57.9%),whichislowerthanboththemeanscoreamongstthesamplerecruitedfortheinstrument’sdevelopment(Wright,Wallston,Elasy,Ikizler,&Cavanaugh,2011)andamongstasampleusedinarecentAustralianresearchproject(Bonneretal.,2014;seeFigure14).KnowledgewashighestforareassuchasunderstandingthattherearestagesofCKD(89.5%correct),thatCKDincreasesriskofheartattack(94.7%correct)anddeath(89.5%correct),andthatthekidneycleanstheblood(89.5%correct).KnowledgewasespeciallylowregardingthefactthatsomeonewithCKDmayexperiencenosymptomsandunderstandingwhytoomuchproteinintheurineisbadforthekidney(both89.5%incorrect).

0

4

8

12

16

20

24

28Mean KiKS Score

ICDNP Bonner et al., 2014 Wright et al., 2011

Figure 14.CKDknowledge(KiKS)scorescomparedwithotherstudies

Diabetes: Diabetes Knowledge Questionnaire

OnlyfiveparticipantswithdiabeteshadcompletedT0assessmentattimeofwriting,andtheiroveralldisease-specificknowledgewaslow.ThemeanscoreamongstType2diabetics(80%ofthesample,fouroutofthefiveparticipants)was18.3,whichislowerthanthemeanscoreforpeoplewiththistypeofdiabetesreportedbyEigenmannandColagiuri(2011)intheirsurveydevelopmentpaper(seeFigure15).OnlyoneparticipanthadType1diabetes,andtheirscorewas26.5,whichisalsolowerthanthemeanscorereportedforpeoplewiththistypeofdiabetes,thoughthedifferencewasnotaspronounced.ParticipantsdisplayedgoodknowledgeofdesirableHbA1cresults(100%correct)andofsomeofthebenefitsofphysicalactivity(bloodsugarcontrolandlowerbloodpressure,both100%correct),aswellastheamountofphysicalactivitythattheyshouldaimtoget(100%correct).Theyalsounderstoodthatgoodcontrolofdiabetesdecreasestheriskofkidneydamage

(100%correct),andthattheNationalDiabetesServicesScheme(NDSS)allowsfor

reducedpricebloodglucosetestingstrips.Importantly,

100%ofparticipantsknewwhattodoiftheyexperiencedanepisodeoflowbloodglucose.Lowest

levelofunderstandingwasregardingdietaryguidelinesfor

diabetes(80%incorrect).

The specialist only just

tell it what is in the blood test and everything and …they not going in that deep talk. Yeah and [the NP] is the deep talk... If I

can’t, if I can’t understand I ask it – what that’s mean, what’s this …? Yeah, yeah … it’s

helped me lot [Patient]


0

4

8

12

16

20

24

28

32Mean DKQ Score

Type 1 Type 2

ICDNP Eigenmann & Colagiuri, 2011

26.5 29

18.3

26

Figure 15.Diabetesknowledgequestionnaire(DKQ)scoresbytypeofdiabetesandotherstudies

Heart Failure: Dutch Heart Failure Knowledge Scale

KnowledgeofHFamongstparticipantswiththisprimarydiagnosiswasmoderate.ThemeanscoreontheDHFKSatT0was11.7,whichishigherthanhasbeenfoundamongstpatientsbeforeHFeducation,butlowerthanfoundamongstpatientswhohadbeenreceivingHFeducation(vanderWaletal.,2005;seeFigure16).Allparticipantsunderstoodthatitwasimportanttotaketheirmedicationregularly,regardlessofsymptomsorlackthereofandthatdiureticsmaybeprescribedtodecreasefluidretention.LessthanaquarterofHFpatientsrealisedthatacoldorflucouldcausearapidworseningofsymptoms(23.5%correct).

0

5

10

15DHFKS Mean Scores

ICDNP Pre-education; van der Wal et al.,

2005

Post-education; van der Wal et al.,

2005

11.7

10.9 112.4

Figure 16.Dutchheartfailureknowledgescores(DHFKS)comparedwithotherstudies

Objective 3b: Self-care BehaviourChronic Kidney Disease: Chronic Kidney Disease Self-Management Instrument

TheCKDself-managementinstrumentwassubstantiallymodified(withpermission)fromLinetal.,2013;itisnotpossibletocomparescores.CKDpatients’meanself-managementscorewas91.3,outofapossibletotalof124(73.6%).Participantsreportedahighlevelofself-managementconfidencewithregardtotheirmedications,includingrememberingtotakethem,evenwhenout(84.2%reportedalwaysdoingthis)andtakingthemasprescribed(94.7%reportedalwaysdoingthis).Similarly,mostparticipantsreportedalwaysfollowingrecommendationsnottosmoke,andthattheywouldalwaysasktheirhealthcareteamformoreinformation,shouldtheydesireit(both84.2%).Confidenceintalkingwithothersabouttheirconditionwaslow,with47.4%ofpatientsreportingthattheyneverdiscussquestionsabouttheirdiseasewithfamilyandfriendsand68.4%reportingthattheyneverdiscusstheirdiseaseexperienceswithotherpatientswithCKD.

Diabetes: Summary of Diabetes Self-Care Activities

Participantswithdiabetes’regularityofengaginginself-carebehaviourwasvariableacrossdifferentbehaviours.Meanscoresforgeneraldiet,specificdiet,andfootcarescoreswerealllowerthanthosereportedbyToobert,Hampson,andGlasgow(2000)acrosssevenstudies.Meanscoresforbloodglucosetestingandexercisewerehigherthanthosereportedinthispreviousresearch(seeFigure17forfurtherdetail).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Summary of Diabetes Self-Care Activities

General Diet Specific Diet Exercise Blood Glucose Testing

Foot Care

ICDNP Clinic Toobert et al., 2000

Figure 17.Diabetesself-careactivitiesscorescomparewithotherstudies


Heart Failure: Self-Care in Heart Failure Index

TheSCHFIassessesmaintenance(i.e.,engaginginimportantself-carebehaviours),management(i.e.,takingactionwhensymptomsoccur),andconfidence(i.e.,beliefthatonecanadequatelycontroltheirHF).Acrossthesescales,acut-offscoreof70isemployedinordertodeterminewhetherapatientwithHFisself-managingsufficiently(Riegel,Lee,Dickson,&Carlson,2009).Withinthecurrentpopulation,meanscoreswerebelowthiscut-offacrossallscales(seeFigure18).Onlysevenpeople(41.3%)scoredabove70ontheMaintenancescale;four(36.4%)scoredabovethecut-offontheManagementscale;andeightpeople(47.1%)didsoontheConfidencescale.

0

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60

80

100Self-Care Heart Failure Index Mean Scores

Maintenance Management Confidence

68.8

48.2

64.1

Figure 18. Self-careinheartfailurescores

Objective 3c: Chronic Disease Self-efficacyAllparticipantsregardlessofprimarydiagnosiscompletedthesixitemchronicdiseaseself-efficacymeasuretodeterminetheirconfidencetomanagetheirchronicdisease.Overallself-efficacywasnothigh(M=6.6),however,itwashigherthanthemeanscoreamongstchronicdiseasepatientsinpreviousresearch(M=5.2;Lorigetal.,2001;seeFigure19).Overall,participantsweremostconfidentthattheycouldcarryoutself-managementtaskssufficientlytoreducetheirneedtoseeadoctor(M=7.3),andwereleastconfidentthattheycouldpreventthefatigueassociatedwiththeirillnessfrominterferingwiththethingstheywanttodo(M=6.2).

1

3

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9Chronic Disease Self-Efficacy Mean Scores

ICDNP Stanford

6.6

5.2

Figure 19.Chronicdiseaseself-efficacyscorescomparedwithotherstudies

Objective 3d: Health-related Quality of Life: SF-36Health-relatedqualityoflifewasmeasuredwiththeSF-36.Thismeasureprovidesinformationabouteightdifferentareasofqualityoflife.Meanscoresforclinicattendeesaswellasmeanscoresfromthesampleusedfortheinstrument’sdevelopmentintheMedicalOutcomesStudy(MOS;Ware&Sherbourne,1992)canbeseeninFigure20Allscalesindicatequalityoflifefrom0(worst)to100(best).Ascanbeseen,aparticularrelativestrengthamongstparticipantswasemotionalwellbeing(M=74.0).Arelativeweaknesswasinrolefunctioningduetophysicalhealth(M=34.1),meaningthatparticipantswereexperiencingsignificantdifficultyincarryingouttheirdailytasksduetothephysicaleffectsoftheirdiseases.

HRQol SF36 Mean Subscale Scores

41.2

70.6

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60.265.8

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Figure 20. Health-relatedqualityoflifescorescomparedwithnormalpopulationscores.


Objective 3e: Satisfaction with ICDNP ClinicPatient-satisfactionwithnursepractitionercarewasassessedusingthePatientSatisfactionwithNursePractitionerCareforPresentingProblemquestionnairefromtheAUSPRAC(Gardneretal.,2009).Attimeofwriting,14peoplehadprovideddataregardingtheirsatisfactionwiththeNPservice.Satisfactionlevelsregardingthequalityofcareparticipantshadreceivedattheclinicwereveryhigh.Overall,allparticipantswereeithersatisfied(n=2)orhighlysatisfied(n=12)withthequalityofcareprovidedbytheNPs(seeFigure21).AllparticipantsreportedthattheNPsseemedtoknowtheirimportantmedicalhistory(n=12;seeFigure22).ParticipantsalsoreportedthattheNPsassistingwithchangingtheirhabitsorlifestylefortheirchronicdisease(seeFigure23).

Overall, how would you rate the quality of care provided by the NP?

Highly

unsatisfied (0

)

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)

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satisfied nor

unsatisfied (0

)Satis

fied (2)

Highly

satisfied (12)

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Figure 21. Levelofsatisfactionwiththequalityofcare

How would you rate the NP’s knowledge of your medical history?

Very poor (0)

Poor (0)

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Good (1)

Very good (1)

Excellent (1

2)0

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Figure 22. NPknowledgeofpatients’medicalhistory

Did the NP give you the help you need to make changes in your habits or lifestyle that would

improve your health or prevent illness?

Yes, somewhat (2)

Yes, definitely

(12)

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I did not need help with this

(0)

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Figure 24. NPhelpwithchanginghabitsorlifestyle

Objectives 5 & 6: Health Service UtilisationMostparticipantshadutilisedhealthservicesinthemonthleadinguptobaselineassessment.Themostcommonlyseenhealthprofessionalwasageneralpractitioner,with92.7%(38)ofthesamplehavingseenoneonceormoreinthatperiod.Figure25displaysthepercentageofparticipantswhohadvisitedvarioushealthservicesinthemonthpriortobaselineassessment.

Health Service Utilisation

GP

Community

Health Centre

Specialist

Doctor

Allied Health

Nurse

Practitioner

Other Health

Service

Not at all Once or twice Three or more times

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

7.3%

75.6%

82.9%

73.2%

24.4%

2.4%

17.1%12.2%

4.9%

61.0%

34.1%

4.9%

65.9%

19.5%

95.0%

2.5%

14.6%

Figure 25. Healthserviceutilisationinthepreviousmonth


… the way the clinic is set up and I

think it’s quite revolutionary around how they’ve done it and I think it could

be rolled out state-wide and …I think the patient outcomes would be greatly

improved [Staff]

Objective 10: Qualitative Interviews and Focus GroupsPatient Interviews

Fourteenpatientsagreedtoparticipateinaninterviewtogathertheirperceptionsofandexperienceswithattendingtheclinic.Overall,patientsreportedattendingtheclinicforvariousreasonswhichincludedhealthadvice,management,andfollow-upfortheirillnesswiththehealthcareteam.PatientsalsoacknowledgedthatattendingtheICDNPclinicreducesthedemandplacedonthehealthcaresystemandisconvenientforthem.Interestingly,patients’knowledgeoftheirillnessandconditionasbeing‘chronic’wasdiscussedandtheydescribedindetailabouttheclinicassistingthemtounderstandandincreasetheirknowledgeoftheirchronicdiseases.Patientsdescribedattendingtheclinicbetween2-15times,mostlyonamonthlybasis,andweresatisfiedwiththelengthoftheconsultationtime.

Overall,patientsreportedsuitabilityinthelocationoftheclinicandfacilities.Patientsdescribedtheeaseofaccess,parking,andofthewalkingdistancefromthecarparktotheclinic.Onepatientofferedfeedbackconcerningsitefacilitiesandrecommendedplacingsomemorechairsinthewaitingarea.

PatientsreportedseveralbenefitsofattendingtheNPclinicwhichsurroundedcommunicationandinteractionwiththehealthcareprofessionals,carereceivedandtrust.Thepersonalapproachtotheircare,communicationandmanagementwashighlighted.PatientsidentifiedimprovementsinhealthandbetterunderstandingoftheirconditionasaresultofattendingtheNPclinic.Theyalsoemphasisedtheimportanceofcontinuityofcareintheirfollow-upwiththesamestaffonaregularbasis.Nobarrierswereidentified.

Overall,patientsidentifiedthevariouswaysinwhichtheNPclinichassupportedthemandthemultidisciplinaryteaminvolvedintheircare.Patientsdescribedreceivingremindertelephonecallsandpostalmail.Furthermore,themonitoringandsupportwashighlightedwithpatientsemphasisingaccesstoNPsasbeingonly“aphonecallaway”ifneeded.

PatientreportedattainingverbalandwritteninformationabouttheirillnesspredominantlyfromconsultationwiththeirNP.PatientsalsoidentifiedthataccessinginformationfromtheirdoctorinadditiontotheirNP.

Interestingly,withtheavailabilityoftheinternetasaninformationsource,onepatientreportedforgettingthat‘Google’wasavailabletosearchforinformationrelevanttotheirclinicalconditionandmanagement.

PatientshighlightedhowattendingtheNPclinichasresultedinincreasesintheirconfidenceandknowledgetounderstandtheirconditionandmanagement.Whileidentifyingtheeffectsonknowledgeandmanagement,patientsalsohighlightedwaysinwhichtheybelievetheclinichasimpactedonthem.Thesewere:

1. Enhancedconnectionwiththehealthcareteamandservice,

2. Lessrelationshipbarriers;

3. Highlypersonalised/individualisedservice;

4. Trustinthehealthcareprofessionalandknowledge;

5. Educationpresentedinlayterms;

6. Knowingthehealthcareprofessionalisthereforthem;and

7. Patientsidentifiedthatafterattendingtheclinic,theygohomewithbetterunderstandingtheirchronicdiseaseandmanagement.

Forinstance,oneparticipantstated:

it’s more personal as opposed to the hospital environment. You feel more connected with the nurse practitioners and advice given to you is easily taken on board, without distractions. I think yeah just totally benefit, I’d rather come here any time than go to a hospital. Maureen does a top job of it, so I know exactly where I’m standing, you know what I mean, and for my benefit – I’ve got nothing bad to say about it at all.

Patientswereveryopenandthoughtveryhighlyoftheclinicinthesupportandmanagementoftheirillness.SomepatientshighlighteddifferencesbetweentheNPclinicandtheGPidentifyingthatmoretimefortheirconsultationwasavailable,aswellasgreaterinformationdeliveredandthus,betterunderstandingofinformationafterattendingtheNPclinic.Forexample:

• OnepatientidentifiedthattheirGPdeliveredinformation;however,theNPexplaineditinfurtherdetail.

• AnotherpatientreportedunderstandingtheirGPmore,asopposedtotheNP.


DifferencesbetweenthehospitalandtheNPclinicwereidentifiedinthattheNPclinicofferedcontinuityofcare(i.e.,follow-upwiththesamehealthcareprofessionals),andthattrustingandeffectiverelationshipscouldbedeveloped.OnlyasmallnumberofpatientsbelievedtherewasnotadifferencebetweentheNPclinicandthehospital.MostpatientsbelievedtheirneedsweremetandthatpotentialhospitalreadmissionsmayhavebeenavertedasaresultofattendingtheNPclinic.

Onepatientstated:

When I come to the nurse practitioner clinic I’m speaking to 2 people who are very, very knowledgeable and speaking to the … in a time period where it’s not rushed or anything like that when you got to a GP you’ve only got 15 minutes for everything if you’re lucky so it’s been good that way, it’s been educational as well as support.

AllpatientsreportedhighconfidenceintheNPclinic.Patientsidentifiedhavingfullconfidenceintheclinicandknowledgeofthehealthcareprofessionals,whichcontributedtotheirpeaceofmind.PatientsalsoreportedconfidenceinNPs’medicationknowledge,andhealthmanagement.ThetimededicatedtoconsultationswasrecognisedasabenefitincomparisonwithshortGPappointments.Furthermore,patientsfeltreassuredandcomfortedinthattheNPswereonlyaphonecallaway.Nosuggestionsforimprovementtotheclinicandcontentwereoffered.

Afinalwordfromapatient:

No it is first class, it just ticks every box. There should be more of them for other people and then that way it would probably reduce the numbers going to the hospitals all the time, by giving people who want to deal in specific areas.

Stakeholder Focus Groups

Threefocusgroupswereconductedwithstakeholderscomprisingnurses,doctors,alliedhealthprofessionalsandadministrationofficers.Duetothepossibilityofidentifyingindividualstaff,thereportreferstoallparticipantsasHealthcareProfessional(HCP).Thehealthcareprofessionalfocusgroupsessionhighlightedthemultidisciplinaryteams’impressionsoftheservice,structure,location,accessibilityandthebenefitsthattheserviceprovidestopatientswithchronicdisease.Furthermore,analyticalfindingsdetailedtheeffectivenessoftheNursePractitioner(NP)rolecoupledwithmultidisciplinaryteaminvolvementinpatientcare.Teamcommunication,facilitatingeffectiveself-

management,NPservicepromotionandawarenesswerehighlighted,withlimitationsandrecommendationsprovidedtoenhancetheclinicsforthefuturegiventhecurrenthealthcareclimate,ageingpopulationanddemandsplacedonthehealthcaresystem.ThefollowingsectiondiscussestheNPclinic,theserviceanditsadvantages.

The NP Clinic: As a service and advantages Healthcareprofessionalsrecognisedtheserviceashighlybeneficialtopatientswithdiabetes,renalandheartfailurereiteratingtheirstrongsupport.HCP1highlightedthepotentialbenefitstopatientswithstages1,2,and3chronickidneydisease(CKD)andhowlifestylechangesrequiringaddressingcouldbeeffectivelyundertakenandmanaged.HCP1alsoreinforcedthebenefitsofseeingaNPandreportedthereductioninfrequencyofvisitstotheirspecialistsasaresultofattendingtheNPclinic.Forinstance,HCP1stated:

I think for some people, selective cases it’s more beneficial them being there than actually coming to the [specialist] physician clinic. And we’re keeping an eye on those sorts of patients with the medical issues and probably seeing them instead of perhaps every two or three months, they’re being seen six monthly or annually instead.

Additionally,givensomeofthepatientsattendingtheclinicareoflowersocioeconomicstatus,healthcareprofessionalsrecognisedthefinancialbenefitsofattendingtheoneclinictoseetheirhealthcareteam.Themultidisciplinaryteam,coupledwitheducationofferedandtimedevotedtopatientconsultations,washighlightedasimportantandvitalinachievingpatientoutcomes.

ThebenefitsofattendingtheNPclinicidentifiedbyhealthcareprofessionalsincludedthemultidisciplinaryteamenvironmentandabilitytoseeallpractitionersintheonevisitasopposedtomultipleconsultations.Furthertothis,multidisciplinaryteamcommunicationwasraisedwithrespecttopatientmanagement.Practitioners

I’m very confident of what

I receive here and again because you feel comfortable when you come here to be able to –

if you feel something you don’t understand you can ask and it’s explained. They notice if you are a bit

upset and ask you why and things like that [Patient]


highlightedthebenefitsofbeingpositionedwithotherhealthcareprofessionalsinthattheycouldcommunicatemoreefficientlyandeffectivelyregardingtheirpatentsandmanagement.Overall,theNPClinicwasviewedpositivelybyallparticipantsinthefocusgroup.DiscussionfromstakeholdersregardingtheroleofNPsinmedicationmanagementandtitrationispresentedbelow.

The NP Role in medication management and titration HealthcareprofessionalsidentifiedtheabilityforNPstoindependentlytitratecertainmedications,suchasdiuretics,insulinandphosphatebinders.Consultationwiththemedicalpractitionerpriortotheprescriptionofnewmedicationswashighlightedandreportedlyoccursverywellinthepresentclinic.Overall,medicationtitrationappearstobedoneaccuratelyandsafely,withNPscommunicatingwiththeirspecialistspriortotheprescriptionofnewmedicationsasidentifiedbyhealthcareprofessionals.TheNPclinicstructureandrecommendationsforfutureclinicsarehighlightedbelow.

The NP Clinic: Accessibility, team support, issues and limitations Theclinicwasidentifiedbyhealthcareprofessionalsasaccessible.Thesefindingsreinforceparticipantinterviewswithpatientsreportingeaseofaccessibility,parkingandgeneralfacilitiesattheclinic.PotentialissuesmayariseforparticipantsashighlightedbyHCP5iftheclinicmovestotheBrownsPlainsarea.Patientissuesidentifiedincludedpatientselectionfortheclinic.Healthcareprofessionalshighlightedthattheselectionofpatientsforreferraltotheclinicrequirescarefulconsideration.HCP1identifiedstablepatientsasmoremanageablecandidatesandthus,bettersuitedtothisclinicandsetting.Alliedhealthsupportwasrecognisedasparamountwithhealthcareprofessionalsidentifyingtheimportanceoftheircontributiontotheclinicandpatientmanagement.

CommunicationandapotentialgapinthecurrenthealthcaresystembetweenGPs,hospitalsandoutpatientdepartmentswasidentifiedbyhealthcareprofessionals.Healthcareprofessionalsrecognisedpotentialinaccuraciesinpatients’medicationlistsalongwithpoormedicationcomplianceandadherence.TheroleofapharmacistintheNPclinicwasraisedtopotentiallybridgethegapandenhancecommunicationbetweenthemultidisciplinaryteam,andpatient.

Lastly,healthcareprofessionalsidentifiedtheimprovedcommunicationandlinksbetweentheGPsandtheclinic.HealthcareprofessionalshighlightedthatGPsappeartobemoreeffectivelymanagingthelowerriskrenalpatientsandasaresultreferringthoseinlaterstagesofCKDto

theNPclinicthatarerequiringreferral.Furthermore,easeofaccesstopatientcareplansthroughGPswasidentifiedbyalliedhealthteamtherefore,demonstratingenhancementsincommunication.Nursepractitionerawarenessandpromotionwereidentifiedinanalyticalfindingsandarediscussedbelow.

NP Clinics: Awareness and promotion TheNPcliniciswellrecognisedinterdepartmentallyandisattributedtotheoutstandingworkandendorsementoftheNPsasreportedbythehealthcareprofessionals.Whilethisisthecase,otherintegratedclinicsarenotaswellrecognisedasverbalisedbyparticipants.Healthcareprofessionalshighlightedtheimportancefortheclinicstoholdongoingeducationalsessionsandreiteratevitalinformation.Healthcareprofessionalsalsoreportedthecost-effectivenessoftheclinics(i.e.,onthehealthcaresystem).ItwassuggestedthatthefundssavedbymanagingpatientsatNPclinicsbeinvestedintostrengtheningalliedhealthsupportatNPclinicsparticularlyinthemanagementofhigherriskpatients.RecommendationsforfutureNPclinicsareidentifiedbelow.

The NP Model: Recommendations for the future Overall,healthcareprofessionalsrecognisedtheimportanceandbenefitsofNPClinics.Thegrouprecommendedinvestmentofgreaterfundstoincludeamultidisciplinaryteamtostrengthenthecareandmanagementofpatientswithchronicdiseaseinthecommunityandtoreducethedemandsplacedonthehealthcaresystem(i.e.,reductioninhospitalreadmissions).Healthcareprofessionalsofferedimportantfeedbackinthepositioningandsetupoffutureclinicsidentifyingcloseproximitytoahospitalforeaseofaccessforpatients.Forcurrentchronicdiseaseclinicsintegratingtheclinicwasrecommended.Overall,healthcareprofessionalswerehighlysupportiveoftheNPclinicandcommendingtheworkundertaken.Suggestionforstatewidemodelfundingforalliedhealth(i.e.,podiatry,pharmacy,socialwork)tosupportNPsandenhancethemodelofcarewashighlighted.

OneHCPnotedthat:

I think it’s quite revolutionary around how they’ve done it and I think it could be rolled out state-wide and around the fact that rural and remote areas like outreach areas like your Cairns, your Townsville your outreach places from that if they have nurse practitioners in those areas and they haven’t got the medical support around that I think the patient outcomes would be greatly improved if they had similar systems out there.


Conclusions and RecommendationsThefirst12monthsoftheICDNPclinichasprovedtobeverysuccessfulwith55patientsattending258appointments.Overall,patientandstakeholderfeedbackwasextremelypositive.MostofthepatientsdidnotpresenttotheEDorrequireadmissionasaninpatient.ThosepatientsthatdidpresenttotheEDhadheartfailure,andduetotheNPreferraldocumentation,EDwhereadvisedtoadmitstraightintothehospitalinthehomeservice;thusfurtheravoidinganinpatientadmission.ForCKDanddiabetespatients,clinicaltargetswerethefocusofattentionalthoughduetotheshorttimeframeofthisevaluation,weareunabletoreportonwhetherimprovementstoclinicaltargetswereachieved.

The Evaluation Team make the following recommendations:

Recommendation 1 ThatLoganHospitalcontinuetoprovideanintegratedchronicdiseaseserviceforpatientswithmultiplechronicdiseases,andconsiderexpandingtheserviceforthosewithotherchronicdiseases(e.g.respiratorydisease,mentalillness).

Recommendation 2 Thattheintegratedchronicdiseaseservicedevelopamission,visionandstrategicplanforthenextthreeyears.Aperson-centredapproachshouldframetheplanandactionsoftheservice,andthatthisapproachwouldexpandtheservicetobemultidisciplinary.

Recommendation 3 ThattheintegratedchronicdiseaseservicedevelopstrongerlinksandreferralpathwayswithGeneralPractitioners,SpecialistMedicalPractitioners,AlliedHealthprofessionals,HospitalintheHome,andinpatientservices.

Recommendation 4 ThattheNursePractitionersassignedtotheservicedevelopcapabilitytoproviderelief/back-fillofeachotherduringtimesofleave.

Recommendation 5 Thelowlevelsofeducationarelikelytocontributetolowhealthliteracyskillsofpatientsattendingtheservice.Thisfindingrequiresthatstaffusearangeofcommunicationstrategiestoensurepatientsunderstandtheirtreatmentplansandthatresourcesareeasytounderstand,useandacton.

Recommendation 6 Thattheintegratedchronicdiseaseservicebeconductedinanaccessiblelocation(easeofaccess,transport,carpark).

Recommendation 7 Thatcontinuedresearchisconductedto:a)assessforchangeinclinicaland/orpatient-reportedoutcomesfollow-up;andb)provideevidenceforfurtherfundedinterventionstoimprovepatientknowledge,self-efficacyandself-management.


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Integrated Chronic Disease Nurse Practitioner Service REPORT... · practitioner (ICDNP) clinic for improving patient outcomes and decreasing health service utilisation, as well as