Melbourne Health. Drug & Alcohol Nurse Practitioner Model

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1 Melbourne Health Drug & Alcohol Nurse Practitioner Model 2009 Model Development Project Victorian Nurse Practitioner Project Phase 4 Round 4.6 (Alcohol and Drug Services)

2 Authors Elizabeth Mackey Nurse Practitioner Project Nurse Patricia Green Drug and Alcohol Clinical Nurse Consultant, Addiction Medicine Service November 2009 Contact Drug & Alcohol Nurse Practitioner Model Development Project December

3 Contents Definitions / Abbreviations...3 EXECUTIVE SUMMARY...4 INTRODUCTION...5 Nurse Practitioners...5 Nurse Practitioners at Melbourne Health...6 SECTION 1: THE ADDICTION MEDICINE SERVICE...7 Addiction Medicine Patients service background...7 Overview of current service model...7 Current Drug and Alcohol Clinical Nurse Consultant Role...9 The Drug and Alcohol Nurse Practitioner in Australia...10 SECTION 2: GAP ANALYSIS...12 Addiction Medicine Service gaps / needs...12 SECTION 3a: DRUG & ALCOHOL NP MODEL...13 Introduction to the model...13 Definitions...15 Service need...15 Where and who...15 Inclusion Criteria...15 SECTION 3b: D&A NP MODEL FLOWCHARTS...18 SECTION 4: D&A NP MODEL IMPLEMENTATION...20 Alignment with Melbourne Health plans...20 Support for the D&A NP role from key stakeholders...20 Budget...20 Candidate education program and other resources...20 Further infrastructure supports...21 Succession planning and role sustainability plans for this role...21 REFERENCES...22 APPENDICES...23 Appendix 1 Guidelines for Addiction Medicine practice...23 Appendix 2 Health Minister (Vic) Approved Drug and Alcohol NP Formulary...24 Appendix 3 Addiction Medicine Service - Gap Discussion and Recommendations...25 Drug & Alcohol Nurse Practitioner Model Development Project December

4 Definitions / Abbreviations AOD CNC D&A NBV NP NPC VAADA Alcohol and/or other drugs Clinical Nurse Consultant Drug and Alcohol Nurse Board of Victoria Nurse Practitioner Nurse Practitioner Candidate Victorian Alcohol & Drug Association Drug & Alcohol Nurse Practitioner Model Development Project December

5 EXECUTIVE SUMMARY The Nurse Practitioner (NP) role is regulated by the Nurses Board of Victoria. The NP is required to be endorsed by the NBV for an extended scope of practice, following extensive clinical and academic preparation. Melbourne Health Addiction Medicine Service manages patients with issues with alcohol and/or other drugs (AOD), as primary care providers or following referral from units treating patients with secondary AOD issues. An Addiction Medicine Service gap analysis and stakeholder engagement as part of the Drug and Alcohol (D&A) NP model development elicited four main areas in which the Addiction Medicine Service s D&A NP may help fill gaps in current service provision. These include: 1. D&A NP led primary and secondary consultation service for inpatients with drug and alcohol issues 2. Consultation for Emergency Department patients with primary drug and alcohol issues 3. Outpatient clinic management of patients with alcohol issues in collaboration with the Addiction Medicine Medical Consultant and referring services e.g. Pain Services (Acute and Chronic), Liver Clinic 4. Tertiary consultant / Staff education on addiction issues. The key gaps in the Addiction Medicine Service are related to only 18 hours medical coverage (medical consultant and HMO) each week with the Addiction Medicine Consultant a 0.3 EFT position and thus limited access to the service for patients with AOD issues. An important aspect of the D&A NP role will be around using a no wrong door approach to facilitate timely and accessible service for primary and secondary patient consultations. Characteristics of the D&A NP should include: flexibility with service provision; ability to engage in client, health professional and community education; advanced assessment skills; advanced counselling skills; ability to appropriately order and interpret diagnostics and prescribe medications; facilitate withdrawal and AOD management; provide certification of leave of absence; and facilitate linkages for AOD services on discharge. Extensions of scope of practice for the D&A NP include making and receiving referrals to other health practitioners, ordering investigations and prescribing from the D&A NP formulary. Patient inclusion will be those that fit within the D&A NP s scope of practice. Patients excluded from D&A NP-led care will be those deemed inappropriate by the treating D&A NP, the Addiction medicine Consultant, and/or the referring team due to increased complexity or complications. Drug & Alcohol Nurse Practitioner Model Development Project December

6 INTRODUCTION Nurse Practitioners The Nurses Board of Victoria has accepted the following Australian Nursing and Midwifery Council (ANMC) definition: A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession s values, knowledge, theories and practise and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise (ANMC, 2006). The standard of practice required for endorsement as a NP is guided by the ANMC National Competency Standards for the Nurse Practitioner (2006). These build on the core competency standards for registered nurses and midwives. These competency standards provide the NP with the framework for assessing competence, and are used by the Nurses Board of Victoria to assess a Nurse Practitioner Candidate s eligibility for endorsement as a NP (NBV, 2008). The following assumptions underpin the use of the competency framework: 1. The nurse practitioner is a registered nurse whose practice must first meet the following regulatory and professional requirements of Victroia National Competency Standards for the Registered Nurse (ANMC, 2006) Code of Ethics for Nurses (ANMC, 2008) Code of Professional Conduct for Nurses (ANMC, 2008) 2. The NP standards are core standards that are common to all models of NP practice and ensure safe NP practice that relates to a specific field of health care. They can accommodate specialty competencies that are designed to meet the unique health care needs of specific client / patient populations. 3. The NP standards will be used by NP education providers to develop the content and process requirements for a nurse practitioner education program. 4. The NP standards will be used by regulatory authorities to determine the eligibility of NPs seeking authorisation as NP in Australia. Nurse Practitioners must demonstrate competence across three standards. They are (ANMC, 2006): 1. Dynamic practice that incorporates application of high-level knowledge and skills in extended practice across stable, unpredictable and complex situations; 2. Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability; 3. Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health care. Nurse Practitioners are regulated by the NBV, and Registered Nurses must apply to the NBV for endorsement as a Nurse Practitioner, following academic (at Masters level) and substantial clinical experience. The title of Nurse Practitioner is protected in Victoria through Drug & Alcohol Nurse Practitioner Model Development Project December

7 legislation. The position integrates clinical practice, research, education, management and leadership. The Nurse Practitioner role aims to meet the gaps and add value to patient service delivery from an advanced nursing practice perspective, promoting a seamless and quality service to a specified group of patients. Nurse Practitioners at Melbourne Health The Melbourne Health Nurse Practitioner Strategic Framework 2009 (Melbourne Health, 2009) outlines the process for Melbourne Health to provide considered support for the Nurse Practitioner role, and the process for development of Nurse Practitioner roles. The role of the Nurse Practitioner should align itself with Melbourne Health s goals and values. This gives clarity to the purpose of the role and the scope of practice of each NP, and ensures that the culture of care delivery supports patients needs. The Advanced Nursing Practice Steering Committee oversees role and model development. The role of the steering committee is to provide governance and oversight of the design, implementation and evaluation of APN roles within Melbourne Health. Drug & Alcohol Nurse Practitioner Model Development Project December

8 SECTION 1: THE ADDICTION MEDICINE SERVICE Addiction Medicine Patients service background Addiction Medicine Services provide cost-benefits to hospitals through reduced length of patient stay and reduced re-presentation to hospital. Clinical staff learn through consultationbased interactions with the Addiction Medicine Service and patients benefit through appropriate clinical management and referral on discharge. The Addiction Medicine Service s philosophy is to provide a service that links with the referring unit s plans for patient management, whilst counselling patients on ways to solve their alcohol and / or other drug (AOD) problems. The Addiction Medicine Service collaboratively facilitates development of a clear and consistent plan of management, to which everyone subscribes (Gijsbers, 2006). The majority of patients referred to the Addiction Medicine Service have drug and / or alcohol abuse issues as concomitant problems to their reason for admission. Referrals to the Addiction Medicine Service arise when (Gijsbers & Green, 2005): A patient has a known history of AOD use. A patient is exhibiting signs and symptoms that may or not be related to AOD withdrawal or intoxication. A family member may be concerned. A patient may request assistance with their ongoing problem (relapse prevention). Withdrawal signs and symptoms from alcohol and other drugs can be present on admission or the patient may go into withdrawal several hours to a few days after the last drug was consumed (Mayo-Smith et al, 2004; McKeown & West, 2009). Outcomes are improved if withdrawals are prevented as the effects of alcohol withdrawal delirium can increase patient stays by up 10 days (Stanley et al, 2003). Patients referred to the Addiction Medicine Service undergo thorough physical, mental health and psychosocial assessment. Clinical practice guidelines used at Melbourne Health for patients with alcohol and other drug issues are listed in Appendix 1, and provide recommendations for treatment. Overview of current service model Definitions Primary consultation: health professional has direct clinical contact with the patient, assesses the patient and provides and implements a plan for management Secondary consultation: health professional provides telephone / distance advice or advice on ward-round to the treating unit (referrers) for patient management, following collaborative assessment of the patient Tertiary consultation: health professional provides education to treating unit (referrers) to improve the referrer s ability to manage patients The Melbourne Health (MH) Addiction Medicine Service aims to improve the identification, and management of patients attending RMH who have AOD problems which may cause complications during treatment and recovery. The service aims to reduce complications and improve outcomes for patients through better management of AOD issues that are impacting on their admission. This may result in a reduced length of stay. The main strategy is to better equip staff to prevent or manage patient behaviours associated with patients AOD use. The Addiction Medicine Service has two main models for patient management. Firstly, the Addiction Medicine medical and nursing staff perform direct patient assessments and care planning, linking in with referring teams, in the form of primary consultations. Secondly, the Addiction Medicine team provide consultation and education about addiction medicine issues, through secondary and tertiary consultations, enabling referrers to look after the patient s Drug & Alcohol Nurse Practitioner Model Development Project December

9 AOD problems by educating staff about AODs. Assessment and advice is available for the following: Identifying patients at high risk of AOD problems in the wards. Management of AOD withdrawal in hospital, including alcohol, opioids, psychostimulants, cannabis, benzodiazepines and other mind altering drugs, either singly or in combination. Assessment and advice for managing pain in patients who are opioid tolerant or resistant because of illicit drug use of opioid substitution pharmacotherapy. Assessment and advice on post-discharge management of patients with AOD problems. (Melbourne Health, April 2009). The Addiction Medicine Service has the following staff and EFT: Medical staff (18 hours per week) o Addiction Medicine Medical Consultant (0.3 EFT) o Addiction Medicine HMO position (0.5 EFT, rotating position every 3 months) Drug and Alcohol Clinical Nurse Consultant (1 EFT) The Addiction Medicine Service, managed under the Division of Medicine, began The number of referrals has been steadily increasing (see Table 1). The types of drugs used by patients referred to the service are mainly alcohol and opiates (see Table 2). Table 1: Addiction Medicine referrals by year Year (Nov) No of Patient s referred to the service Table 2: Types of Drugs referred to Addiction Medicine Service % 7% 10% 23% 51% Alcohol Opiates Cannabis Benzo Amphet/Meth/MD A/GHB Each referred patient is seen an average of 2.5 times. The main referral units include Trauma, General Medicine, Psychiatry and the Emergency Department. (DHS, 2009, p.42) notes: In , more than 20,000 bed days in Victoria s public hospital system were utilised by people in a state of withdrawal while being treated for other medical and mental health conditions. Withdrawal adds to the complexity of treatment with an average bed day per separation of 7.6 days. There is an opportunity to strengthen prevention initiatives through the hospital system. Drug & Alcohol Nurse Practitioner Model Development Project December

10 Public hospitals in had over 3,000 separations where patients were withdrawing from AODs: the average stay per patient was 3.7 bed days (DHS, 2009, p.42). In the past year at Melbourne Health the number of patients referred to the service was 435 (see Table 3): of these 34 patients (7.8%) were commenced on substitution pharmacotherapy (methadone or buprenorphine for withdrawal) indicating the need for registered prescribers of substitution pharmacotherapy. Currently the only registered substitution pharmacotherapy prescribers at the Royal Melbourne Hospital are A/Prof Alan Gijsbers, the Addiction Medicine Medical Consultant, and Dr Malcolm Hogg, the Pain Service Consultant. Dr Hogg assists for substitution pharmacotherapy patients when A/Prof Gijsbers is on leave. Table 3: Breakdown of patient groups referred to Melbourne Health s Addiction Medicine Service (Nov 08-Oct 09) Total Episodes: Separations Average Length of stay Inlier Episodes: Separations Average Length of stay V60A ALCOHOL INTOXICATN&WITHDRWL+CC V60B ALCOHOL INTOXICATN&WITHDRWL-CC V60Z Alcohol Intoxication and Withdrawal V61Z Drug Intoxication and Withdrawal V62A Alcohol Use Disorder and Dependence V62B ALCOHOL USE DSRD & DEPENDNC+SD V63A OPIOID USE DSRD & DEPENDENCE V64Z OTHER DRUG USE DISORD & DEPEND Total Current Drug and Alcohol Clinical Nurse Consultant Role The Drug and Alcohol Clinical Nurse Consultant (D&A CNC) provides primary, secondary and tertiary consultations and advice on complex withdrawal issues and longer-term management for patients at the Royal Melbourne Hospital and secondary consultations to the Royal Park Campus. Currently the D&A CNC works with the Addiction Medicine Medical Consultant and / or Hospital Medical Officer (HMO) for 18 hours per week. The Addiction Medicine Medical Consultant has seven-hours of ward rounds and is available on-call at other times. However the on-call availability is not a paid service and may not be available on demand. The D&A CNC currently provides education and mentorship for the Addiction Medicine HMO staff in the absence of the Medical Consultant. The current role is summarised in Table 4. Table 4: Drug and Alcohol Clinical Nurse Consultant Role Summary: Role requirements Nurse with training and experience in Drug and Alcohol Services This role works closely with the Addiction Medicine Consultant Patient Screening The CNC works with staff to improve screening and identification of patients with potential drug and alcohol risk factors, which will then be incorporated into their pre-admission work up and care plans. This would pre-empt complications, e.g. anaesthetic risk, withdrawal during their Drug & Alcohol Nurse Practitioner Model Development Project December

11 inpatient stay. Patient Coordination The Co-ordinator is the first point of access for the service and takes referrals from ED, Outpatients and Pre-Admission Clinic, as well as inpatient units. Works closely with the Addiction Medicine Consultant, providing a consultation service to MH on management of patients with Drug and Alcohol problems through ward rounds, individual consultation and referral. The Co-ordinator works with the Addiction Medicine Consultant to provide education and support for staff in targeted areas (those where impact of patients Drug and Alcohol problems may be greatest). This will cover screening, medical management and behavioural management and links to available support services. It will also entail development of clinical guidelines for management of this patient group. Staff Support and Links To assist and support staff in the development and implementation of Drug and Alcohol nursing care plans. To evaluate current process of documentation and participate in the development and implementation of best practice documentation. To foster liaison with other Drug and Alcohol stakeholders. Research and Quality To actively participate in any research or evaluation processes related to the target group. To actively participate in related working parties such as aggression management, restraint and code grey calls. To ensure that the objectives, policies, rules and regulations established by the Addiction Medicine Service, MH, & / or higher authorities are implemented. The Drug and Alcohol Nurse Practitioner in Australia In Victoria, there is one D&A NP, working at Uniting Care Moreland Hall a 12 bed Community residential drug withdrawal unit. The D&A NP also works on occasion in Homebased, Outpatient and Youth Withdrawal. The Nurse Practitioner works where possible in Shared Care with General Practitioners whose patients enter treatment for residential withdrawal. There may be occasion to provide treatment for patients who have no General Practitioner. Treatment is provided only during their admission into the residential withdrawal service (Uniting Care Moreland Hall, 2009). There are two registered Drug and Alcohol Nurse Practitioners in New South Wales (NSW), one at the John Hunter Hospital and the other at the Royal North Shore Hospital and Herbert Street Clinic. For both D&A NPs their patients must be over 16 years of age. The RNSH and Herbert Street Clinic clients may be inpatients or outpatients of the Hospital or the Clinic. The diagnoses and presenting symptomatology / complaints of patients for the NSW D&A NPs include (NSCCAHS, 2007; HNEAHS, 2007): Alcohol related disorders intoxication, withdrawal, and dependence. Nicotine related disorders dependence, cessation and withdrawal. Licit & illicit substance-use disorders intoxication, withdrawal, and dependence. NB: this includes management of patients receiving pharmacotherapies for opioid dependence. This D&A NP case manages and provides consultative input to the care of individuals and responds to the needs of their families, and interacts with other health care providers to the benefit of the patient. The D&A NP provides specialist referral where necessary and recognises the limits of this scope of practice in relation to patients co morbidities (NSCCAHS, 2007). There is a Drug and Alcohol NP drug formulary approved by the Victorian Minister for Health, July 2009 (See Appendix 2). Drug & Alcohol Nurse Practitioner Model Development Project December

12 The Turning Point Alcohol and Drug Centre (2004) review of drug treatment services in Victoria recommended that the Nurse Practitioner role be expanded to the AOD sector to enhance and expand existing drug treatments. The model involves the integration of advanced nursing and health knowledge, skills and clinical expertise into daily practice. This specialist role assists in the promotion of care between health providers and in partnership with clients and communities (Turning Point, 2004, p.78). An important aspect of the D&A NP role is to ensure timely and accessible service. A new blueprint for alcohol and other drug treatment services (DHS, 2008, p.41) states: The no wrong door approach recognises that timely access to the right treatment is critical regardless of whether a person presents for alcohol and other drug treatment; at a needle and syringe program; or at a mental health, primary health, hospital, family or housing services facility. Using the recommendations of Turning Point Alcohol and Drug Centre (2004), the Victorian Alcohol and Drug Association (VAADA, 2005 p.15-16) consulted on the key characteristics of the nurse practitioner role in the alcohol and other drugs sector. Table 5 provides a list of characteristics that are relevant to a D&A NP in Addiction Medicine services within a hospital context: Table 5: Characteristics of a D&A NP (VAADA, 2005, p.15-16) Characteristic Flexibility Personal Education Client and community education Assessment Counselling Diagnostics Withdrawal Prescribing Certification Linkages Funding Further explanation Access to D&A services for clients when it is required rather than when they are able to get a GP appointment Identification and understanding of local cultures, as well as increased educational needs Concerning harm reduction around alcohol and other drug use, and other broader information (eg. blood borne viruses, vein care, wound care, dental care, sexual health and overdose prevention) A holistic approach relating to general, mental and emotional health, as well as alcohol and drug history, followed by appropriate referral, liaison or cocase management with other general health/mental health services Alcohol and other drug counselling, as well as generalist counselling (eg. Pre and post counselling for Hepatitis C and HIV) Pathology testing of blood including full blood examination, electrolytes, liver function and for viruses and sexually transmissible infections Provision of inpatient and outpatient withdrawal services As per approved D&A NP Drug formulary to treat signs and symptoms of withdrawal and for maintenance pharmacotherapy Ability to approve absence from employment / Centrelink requirements during withdrawal period The ability to interact with other services other than alcohol and drug (eg. mental health, domestic violence, family support, employment and housing, education and training programs, parenting support) If introduced, additional funding for nurse practitioners is integral to the effective development of any model Drug & Alcohol Nurse Practitioner Model Development Project December

13 SECTION 2: GAP ANALYSIS Addiction Medicine Service gaps / needs The Addiction Medicine service is within the Division of Medicine at Melbourne Health. Departments from many Melbourne Health Divisions in Melbourne Health use the Addiction Medicine service, including the Divisions of Medicine and Emergency, Surgery and Perioperative (including notably Gastroenterology), Neurosciences, Cardiac, Mental Health and Ambulatory and Continuing Care, and Intensive Care. A gap analysis was completed November 2009 using feedback provided by relevant stakeholders from the above Divisions of Melbourne Health. Interviews were undertaken with medical staff, nurses, allied health staff, and service directors. Four key areas of opportunity were identified for model development and extension of the role of the D&A CNC. These were used to facilitate discussion about gaps in the Melbourne Health Addiction Medicine Service: 5. D&A NP led primary and secondary consultation service for inpatients with drug and alcohol issues 6. Consultation for Emergency Department patients with primary drug and alcohol issues 7. Outpatient clinic management of patients with alcohol issues in collaboration with the Addiction Medicine Medical Consultant and referring services e.g. Pain Services (Acute and Chronic), Liver Clinic 8. Tertiary consultant / Staff education on addiction issues. Primarily, the D&A NP role will ensure responsive timely access to the Addiction Medicine Service Appendix 3 provides a summary of feedback from stakeholders in relation to the current Addiction Medicine Service and how the NP may potentially fill appropriate gaps in the service, based on scope of practice. Drug & Alcohol Nurse Practitioner Model Development Project December

14 SECTION 3a: DRUG & ALCOHOL NP MODEL Introduction to the model The recommendations from Turning Point Alcohol and Drug Centre (2004), VAADA (2005), the Australian D&A NP models, and the service gap analysis have been used to develop the Melbourne Health s D&A NP model. The D&A NP in the Addiction Medicine Service would primarily perform functions of clinical care delivery for patients who have substance-use disorders. The D&A NP role extends the current CNC scope of practice to include advanced assessment, autonomous and collaborative decision making and management (See Table 6). This entails the management of patients with drug and / or alcohol dependency experiencing acute withdrawal issues, including ordering and interpreting diagnostic tests and prescribing medication. The D&A NP would be a registered methadone / buprenorphine prescriber and would be qualified to commence an inpatient on substitution pharmacotherapy. The aim of the model is to enhance the timeliness and responsiveness of the Addiction Medicine Service, and to decrease the length of stay for patients with withdrawal issues or suspected withdrawal issues. The current limited hours of medical consultation is a barrier to inpatient and outpatient service accessibility. The new model will allow greater access for patients with AOD issues to Addiction Medicine Services, through the advanced scope of practice of the NP, and thus will allow enhanced service capacity. The extended scope of practice links in with ANMC (2004) competency standards for Nurse Practitioners (Table 6). Table 6: D&A Nurse Practitioner Role Summary Drug and Alcohol Nurse Practitioner Conducts advanced, comprehensive and holistic health assessment of drug and alcohol patients Assess the biological, psychological and social aspects of each individual patient s drug and / or alcohol issue Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence based and informed by specialist knowledge Autonomously (within scope of nursing practice) and collaboratively (with referring unit) manage patients with drug and alcohol issues, providing linkage to support the patient s return home / to their community Manage and provide consultation for inpatients referred with drug and alcohol issues Lead regular outpatient clinics for patients with primary drug and alcohol issues, and for patients with concomitant drug and / or alcohol issues Provide counselling for patients that may be either motivated or ambivalent to modify their lifestyle to change their drug and / or alcohol use Provide counselling about the physiological aspects of drug and alcohol usebased on individual patient blood results and physical symptoms Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments Develop skills in leading regular outpatient clinics for patients with primary drug and alcohol issues, and for patients with concomitant drug and / or alcohol issues May be asked for advice on community issues and in complex environments such as ICU Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to addiction medicine patient care and the education of others Actively promote evidenced based practice, and educate medical, nursing and allied health staff in drug and alcohol management, medication and associated illness prevention management Applies extended practice competencies within the Drug and Alcohol nursing model Establishes therapeutic links with the patient / carers / community that recognise and respect cultural identity and lifestyle choices Drug & Alcohol Nurse Practitioner Model Development Project December

15 Is proactive in conducting clinical service that is enhanced and extended by autonomous and accountable practice Engages in and leads clinical collaboration that optimise outcomes for drug and alcohol patients and carers Coordinate and facilitate higher level nursing decision making for patients with drug and / or alcohol issues Take on a higher collaborative leadership role within the unit including during the Addiction Medicine round and meetings, in family meeting discussions, and in Addiction Medicine Service activities including projects and research Take on a higher collaborative leadership role with external professional, clinical and community bodies Engages in and leads informed critique and influence at the systems level of health care Develop leadership skills in decision-making, team coordination, and communication Drug & Alcohol Nurse Practitioner Model Development Project December

16 The Melbourne Health D&A NP Definitions Primary consultation: health professional has direct clinical contact with the patient, assesses the patient and provides and implements a plan for management Secondary consultation: health professional provides telephone / distance advice or advice on ward-round to the treating unit (referrers) for patient management, following collaborative assessment of the patient Tertiary consultation: health professional provides education to treating unit (referrers) to improve the referrer s ability to manage patients Service need The Addiction Medicine Service has limited medical consultant cover (18 hours per week), which creates a gap in the service for inpatients and outpatients with AOD issues. The D&A NP role will bridge this gap, and facilitate timeliness and responsiveness for primary consultation referrals for patients with AOD issues. The D&A NP will also enhance the consultation advice in secondary and tertiary consultations. Where and who The D&A NP, as part of the Addiction Medicine Service, will provide care for patients in the following areas of Melbourne Health: 1. Inpatients: D&A NP led primary and secondary consultation service for inpatients with AOD issues, including: a. Pre-Admission Clinic patients identified at risk by GP or Melbourne Health staff prior to admission for elective procedures b. Acute medical wards, surgical wards, and specialty units (e.g. Day Procedure Unit, Intensive Care Unit) c. Acute psychiatric inpatient unit in collaboration with the dual-diagnosis (drug / alcohol and mental health) service based on protocol 2. Emergency Department (ED): Primary consultation for ED patients with primary AOD issues 3. Primary and secondary consultation service for outpatients, including at: a. Addiction medicine Clinic b. Acute Pain Clinic c. Chronic Pain Clinic d. Liver Clinic e. Hepatitis C Clinic f. Methadone Clinic (5-year plan) 4. Tertiary consultations on addiction issues and management of patients with substance abuse disorders. Inclusion Criteria The Addiction Medicine Service is designed to improve the referrer s ability to look after the patients AOD problems. All patients referred to the Addiction Medicine Service will be eligible for primary management / secondary consultation management by the D&A NP, using the no wrong door approach. This cohort of patients has complex needs in their psycho-social-biological domains. Due to the complex nature of this group of patients the majority of the consultations will be secondary consultations with the treating (referring) unit. Exclusion Criteria The D&A NP s scope of practice is bounded by the knowledge and skills of the NP and the agreed Clinical Guidelines and Formulary that will underpin this position. In the context of this scope of practice there will be ample opportunities for the D&A NP to consult specialist Drug & Alcohol Nurse Practitioner Model Development Project December

17 clinicians including D&A (and other-specialty) Staff Specialists, Registrars, Nurses, Psychologists and General Practitioners. The D&A NP will consult or make a referral to a medical officer or specialist medical officer in the following situations: Where signs or symptoms persist beyond the expected time of their resolution despite treatment Where symptomatic or laboratory evidence exists of previously unidentified decreased or decreasing function of any vital organ or system Where a patient presents co morbidities falling outside the D&A NP s expertise eg. Infection, pregnancy, asthma, diabetes. In the event of an atypical presentation of a common illness or an unusual response to treatment Where a patient s chronic condition destabilises, especially an unexpected deterioration in the condition being managed or any existing co morbidity When a patient requires admission or other-specialty review Any other conditions/clinical presentations that the D&A NP and the medical officers have agreed to Any other conditions that the D&A NP believes are outside this scope of practice Access to D&A NP The D&A NP will work across Melbourne Health campuses (City and Royal Park) with inpatients and outpatients in the acute and subacute settings during business hours (Monday Friday). Referral to the service will be via electronic referral and a page or telephone call. Consultation by the D&A NP may be primary where by the patient is reviewed and the plan communicated directly to the staff, and secondary consultation to staff where advice would be offered on management of addiction issues. The scope of practice would be defined by assessment of the addiction issue and management of bio-psycho-social and spiritual issues surrounding drug withdrawal, opioid tolerance and pain management and ongoing treatment options. Clinical review of patients will involve the use of advanced patient management skills. These include advanced assessment including history taking, physical assessment, and care planning in collaboration with patient s treating unit. The D&A NP will order (or make recommendations to the treating unit for orders in secondary consultations) and interpret diagnostic investigations (see below), and will use this information to help formulate a plan of care for the patient. The D&A NP will also prescribe substitution pharmacotherapy and other medications from the D&A NP drug formulary (Appendix 2). Communication of plans will be in the patient medical record and communicated orally to the patient, treating medical unit, nursing staff, pharmacist and allied health staff. The D&A NP will also liaise with the patient s GP and other services, to communicate care plans. Diagnostic Investigations Diagnostic investigations may include: Blood alcohol, Toxicology, Haematology and Biochemistry (FBE, U&Es, Magnesium, liver function tests, coagulation profile (INR), CRP) Immunological status (HIV / Hepatitis B / Hepatitis C) Discharge from the D&A NP service Patients may be referred back to or linked in to primary / community care providers, such as GP, support group or pharmacotherapy provider for ongoing community support. All patients referred to the D&A NP fall under the Addiction Medicine Service. If the management recommendations have been achieved, and following consultation with the treating unit (referrer), the patient, and case review with the Addiction Medicine Service, the patient will be discharged from the Addiction Medicine Service. Drug & Alcohol Nurse Practitioner Model Development Project December

18 Drug Formulary The D&A NP will prescribe within his / her scope of practice. The formulary of this NP is supported by the Melbourne Health policy and sits within the approved NP prescribing drug and alcohol category (Appendix 2). This formulary provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by nurse practitioners under section 14A of the Drugs Poisons and Controlled Substances Act 1981 and forms part of approved nurse practitioner guidelines. It is the Nurse Practitioner s responsibility to use this formulary in conjunction with the most recent product information available. Any alteration must be submitted to the Melbourne Health Advanced Nursing Practice Steering Committee and the Melbourne Health Drugs and Therapeutics Committee. Accountability The D&A NP is accountable for health outcomes. The D&A NP accepts responsibility for all aspects of clinical decision-making. The D&A NP will seek expert advice and make referrals where necessary to ensure quality patient care. The D&A NP will participate in the continuing evaluation of the service in the following quality parameters: safety, patient/clinician access, and efficacy. The D&A NP will ensure that there is evidence of continuing professional development and maintenance of clinical skills in line with NBV Continuing Professional Development. The Addiction Medicine Service regularly goes on ward round together to review clinical decision made by the members of the team. Decisions are discussed, and advice sought using each member s knowledge and skills. The clinical decision process is represented in the flow chart (Figure 1) below, and involves: 1. Medical Consultant provides clinical supervision to NP (Medical care) and HMO (Addiction Medicine speciality) and general Medical care 2. NP provides specialist addiction knowledge to HMO and service co-ordination. Accountable for own decisions. 3. HMO provides general medical knowledge/skills working in collaboration with Medical Consultant and NP. Figure 1: Clinical Decision Process Chief Executive Officer Melbourne Health Executive Dir of Nursing Executive Director of Medical Services Co Divisional Director Nursing Division of Medicine Divisional Director Division of Medicine General Medicine Department Head Addiction Medicine Service 2. D &A Nurse Practitioner (NP) (1.0 EFT) 1. Medical Consultant (0.3 EFT) Head of Service 3. Hospital Medical Officer (2 nd /3 rd Yr HMO 0.5 EFT) 3 Mth Training Position Drug & Alcohol Nurse Practitioner Model Development Project December

19 SECTION 3b: D&A NP MODEL FLOWCHARTS INPATIENTS: D&A NP-led Primary Inpatient Consultations Referral to D&A NP by Pre-Admission Clinic / GP prior to elective admission, Acute medical wards, surgical wards, and specialty units, Acute psychiatric inpatient unit Outside Scope of Practice: Secondary consultation with Addiction Medicine Consultant and/or Referring Team Emergency department presentation Patient management by Addiction Medicine Team Assessment of patient (in patient s ward / unit or Pre-Admission Clinic) of physical health, mental health, psychosocial issues, goals of treatment plan, other supports Development of treatment plan. Communication of treatment plan with patient, referring unit. Documentation in medical record. Treatment in collaboration with referring team, including regular ward round review. Discharge planning in response to post withdrawal and/or ongoing community management of D&A problem Acute medical condition Review with Referring Team Completion of treatment episode. Letter to General Practitioner. +/- Referral to mental health services, Melbourne Health D&A Outpatient Clinic, other alcohol and drug support agency, residential rehabilitation, counselling, psychiatric services. Discharged from Addiction Medicine Service Drug & Alcohol Nurse Practitioner Model Development Project December

20 OUTPATIENTS: D&A NP-led Primary Outpatient Consultations Referral to D&A NP from Addiction Medicine Service, Acute Pain Service, Chronic Pain Service, Liver Unit, Gastroenterology (Hepatitis C) Service Outside Scope of Practice: Secondary consultation with Addiction Medicine Consultant and/or referring team Ad hoc referrals from other Outpatient Clinics Patient management by Addiction Medicine Team Assessment of patient (in Outpatient Clinic) of physical health, mental health, psychosocial issues, goals of treatment plan, other supports Development of treatment plan. Communication of treatment plan with patient, referring unit. Documentation in medical record. Treatment in collaboration with referring team, including regular Outpatient Clinic follow-up. Discharge planning to link patient into community care providers, including GP. Acute medical condition Refer back to Referring Team Completion of treatment episode. Letter to General Practitioner. +/- Referral to mental health services, other Outpatient Clinics, other alcohol and drug support agency, residential rehabilitation, counselling, psychiatric services. Discharged from Addiction Medicine Service Drug & Alcohol Nurse Practitioner Model Development Project December

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