Aged Care Nurse Practitioners developing models

Transcription

1 Faculty of Health Science Aged Care Nurse Practitioners developing models Associate Professor Christine Stirling, Chief Investigator Dr Michael Bentley, Research Fellow Dr Melinda Minstrell, Postdoctoral Research Fellow Professor Andrew Robinson, Professor of Aged Care Nursing Hazel Bucher, Aged Care Nurse Practitioner Lisa Sproule, Nurse Practitioner - Aged Care / Primary Care

2 Background Ageing population Increasing numbers of older people needing services Multi-morbidities - complexity Dementia consistently under-diagnosed Around 50-80% of people with dementia undiagnosed GPs do not regularly screen for, recognise, or document dementia 2

3 Nurse Practitioners Nurse Practitioners (NPs) = advanced clinical skills Masters training with defined scope authorised to function autonomously & collaboratively in an advanced and extended clinical role within defined scope role may include, but not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. in 2000 NP s first endorsed in Australia (NSW) now over 600 NP s in Australia - (similar roles developed in US in 1960s and UK 1980s) Not widely used in the aged care setting 3

4 Nurse Practitioner project Aged Care Nurse Practitioner development national project over 30 sites 3 year pilots IM/NPACT Southern Tasmanian project Nurse-Led Memory Clinic (DHHS) NP within Dementia Behaviour Management Service (DHHS) ACNP GP practice based Thank you to Judith Jane Mason & Harold Stannett Williams Memorial Foundation, administered by ANZ Trustees for their grant supporting the NLMC research this let to a project grant from the Commonwealth Department of Health and Ageing. This was an Australian Government Initiative trialling aged care nurse practitioner models. 4

5 Our Aims 1. Trial a nurse-led memory clinic to assess effectiveness and impact 2. Improve access to primary health, dementia and mental health services for older persons in general practice, residential aged care facilities and community. 3. Demonstrate a sustainable, professionally supported, combination aged care NP role that can add value to general practice while providing independent practice opportunities for the NPs. 5

6 Evaluation Bentley, M and Minstrell, M and Bucher, H* and Morrissey, M* and Robinson, A and Stirling, C, A case study evaluation protocol to assess processes, effectiveness and impact of a nurse practitioner-led memory clinic, Health, 6 (8) pp doi: /health Mixed methods Evaluate memory clinic intervention of 1 NP at 1 day per week over 25 months - Case Study followed between one - two NPs in a general practice over 2 years Data Collection Memory Clinic -Demographic and clinical data from clients, videorecording of consultations, clinic documentation, and interviews with the ACNPs. description of patients, diagnoses, and interventions comparison of NP diagnosis to psychogeriatricians. GP setting - Descriptive and content analysis of de-identified clinical and demographic details of clients episodes of care, Repeated, semi-structured interviews with the NPs. 6

7 The Role Developed Initial NP Services expected Memory Clinic continued one day per week but commenced videorecording assessments Two days per week at GP practice, booked own appointments Initially reviewed all dementia patients Cognitive assessments in the community setting (2 per day) Comprehensive Medical Assessments on elderly patients in Residential Aged Care Facilities, and writing up drug charts 7

8 Memory Clinic Results Minstrell, ML and Bentley, M and Bucher, H* and Morrisey, M* and Higgs, C and Robinson, AL and Stirling, CM, Open referral policy within a nurse-led memory clinic: patient demographics, assessment scores, and diagnostic profiles, International Psychogeriatrics: The Official Journal of The Interntional Psychogeriatric Association pp doi: /s ISSN (2014) Diagnosis of 106 clients assessed 45% received diagnosis dementia or MCI 34% dementia, 13% MCI, 25% depression, 43% no diagnosis 60% self-referred of which 30% had either dementia or MCI 56% of those referred by GP had dementia or MCI 100% of allied health professional referral had dementia or MCI 25 clients were unaccompanied and only 1 diagnosed with dementia 8

9 Memory clinic Difference to other memory clinics More males than other studies Lower education levels than other studies 24% referral were from GPs compared to 59% (+16% other doctors) High % of falls (28% versus 15% Clients had > MMSE than those diagnosed in other studies MCI 28.2 versus 26.2 Dementia 24.1 versus 19 % dementia, MCI depression diagnosis < others Limitations Small numbers differences not statistically significant Limited published information to compare with 9

10 GP Clients Seen: General Clients Weight Loss Clients All Clients N = 125 N = 43 N = 168 Median Age 82 (36-99) Median Age 52 (29-79) Median Age 76.5 (29-99) Male 44% Male 12% Male 36% Female 56% Female 88% Female 64% Median Episodes of Care 3 (1-31) Diagnosis Dementia 15% MCI 6% Multimorbidity 63% Median Episodes of Care 6 (1-12) Diagnosis Dementia N/A MCI N/A Multimorbidity 10% Median Episodes of Care 4 (1-31) Diagnosis Dementia 11% MCI 4% Multimorbidity 53% Multimorbidity two or more multimorbid conditions as defined by the Cumulative Illness Rating Scale domains (Britt et al. 2008). Ten of these clients were in the weight loss program. Twenty-two (85%) of the clients with dementia/mild cognitive impairment also had multimorbidity. 10

11 Episodes of Care For internal UTAS use only Direct Care (all activities performed for and in the presence of the patient/family (Gardner et al. 2010) cognitive assessments, patient assessment and reviews, ordering and/or reviewing tests and medications, and liaising with family members. OR Indirect care (activities performed away from the patient but on a specific patient s behalf: documentation and letters, referrals to/coordinating care with other health professionals - including geriatricians, GPs, allied health professionals (e.g., physiotherapists, dietitians), social services such as home care, and support programs such as programs run by Alzheimer s Australia. 11

12 Key Challenges Demonstrating efficacy of dementia diagnosis Gaining support and confidence from GPs and practice nurses Communication e.g. referrals and correspondence with GPs and nursing staff Determining a sustainable model for the future Access to regular consulting rooms (this access during 2013 meant more clients were seen in the practice Currently Memory Clinic continues other services considering or undertaking similar nurse led approach 1 NP has a contract similar to GPs in practice Access to rooms 2 days per week name on Practice Provides services to Rural Community Health Centres for Practice (gained grants for this role). Extended Aged Care scope to include Primary Care 12

13 Conclusion For internal UTAS use only There is great potential: NPs with dementia diagnosis expertise are very useful in several settings NPs demonstrated expertise and usefulness to services, but combined role more sustainable AND Still a difficult environment to gain acceptance - Need an entrepreneurial nurse and practice, with communication. 13

14 Contact For internal UTAS use only Contact - [email protected] Papers: Bentley, M and Minstrell, M and Bucher, H* and Morrissey, M* and Robinson, A and Stirling, C, 2014 A case study evaluation protocol to assess processes, effectiveness and impact of a nurse practitioner-led memory clinic, Health, 6 (8) pp Minstrell, M, Bentley, M, Bucher H., Morrisey M, Robinson, A, Higgs C., Stirling C. In Print "Open referral policy within a nurse-led memory clinic: patient demographic, assessment score, and diagnostic profiles. International Psychogeriatrics References: Britt HC, Harrison CM, Miller GC, Knox SA (2008) Prevalence and patterns of multimorbidity in Australia. Medical Journal of Australia 189, Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A (2010) The work of nurse practitioners. Journal of Advanced Nursing 66,