Using Nurse Led Clinics

A Team Approach to Managing Preventative

Health & Chronic Disease Care in General Practice

Karen Booth RN

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

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

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

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

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

• 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

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

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)

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

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  

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

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

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

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

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

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?

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

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

Currently Available

• Clinical software inbuilt assessments /care plan

• Dept Health & Ageing

• Division downloadable templates

• RACGP paper care plan

• Make your own

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

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

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).

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

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

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

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

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

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)

• Discuss care plans & content & templates

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

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

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

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

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.

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

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