Department of Health, Nurse Policy Branch: Victorian Nurse Practitioner Project Round 4.5 Oncology services Deliverable 1 WIMMERA ONCOLOGY NURSE PRACTITIONER MODEL OF CARE A collaboration between: Wimmera Health Care Group - Horsham Stawell Regional Health - Stawell East Grampians Health Service Ararat Janette McCabe Oncology Nurse Practitioner Project Officer janette.mccabe@whcg.org.au July 2010 Acknowledgements: The Wimmera Oncology Nurse Practitioner model of care was developed with the assistance of the Oncology Nurse Practitioner Steering Committee and Oncology Nurses and Pharmacists from Stawell, Horsham and Ararat and Professor George Kannourakis from Ballarat. Particular thanks must go to Shyla Bauer and Liz Morley and other members of the Victorian Oncology Nurse Practitioner Community of Practice for their valuable assistance. Thank you also to the health services listed below for generously sharing their reports and models: Bendigo Health, Round 4..5, Oncology Nurse Practitioner Model of Care, 2010 Southern Health, Round 4.5, Oncology Nurse Practitioner Model of Care report, 2010 Barwon Health, Round 4.4, Palliative Care Nurse Practitioner Models, 2009 Wimmera Oncology Nurse Practitioner Model July 2010 1
Setting and Context The application for funding for the Oncology Nurse Practitioner Project (ONPP) project was generated as a collaborative between Wimmera Health Care Group (WHCG), East Grampians Health Service (EGHS) and Stawell Regional Health (SRH) to enhance existing services and develop an innovative model of care for long term sustainability of the Oncology Services in view of the increasing demand and the difficulties of distance. Location of Wimmera collaborative model Each of the three participating health services are situated on the Western highway within the Grampians Integrated Cancer Service area, with EGHS at Ararat 100 kilometres north-west of Ballarat, WHCG at Horsham a further 100 kilometres north-west of Ararat and SRH at Stawell located between the two. Range of Health Care services provided Each of the three organisations operates autonomously and provides a broad range of services to the surrounding region which include: Emergency care Medical management including general medical, palliative and mental health Surgical treatment local general surgeons are supported by visiting specialists from Ballarat for Orthopaedics, Urology, Opthalmology and ENT Oncology Day Units for chemotherapy administration Antenatal and birthing care Wimmera Health Care Group in Horsham is a base hospital with 58 acute beds including a 5 bed Intensive Care Unit plus 22 same-day beds (4 dialysis, 8 day procedure and 10 Day Oncology) and 106 aged care beds at the Horsham campus. The Dimboola annex has 4 sub-acute beds and 26 aged care beds. East Grampians Health Care in Ararat has 29 acute beds including one palliative care bed, 18 sameday beds (4 dialysis, 6 day procedure and 8 Day Oncology) and 85 Aged care beds. The Willaura campus has 8 sub-acute beds 2 high care and 10 low care beds. Stawell Regional Health has 29 acute beds, 16 same-day beds (6 day procedure and 10 Day Oncology) and 36 Nursing home beds. Wimmera Oncology Nurse Practitioner Model July 2010 2
Oncology Services in the Wimmera The current service model includes weekly visits by a Ballarat based Medical Oncologist and Haematologist, who travels to one of the respective health services each Wednesday (two per month to WHCG and one each to SRH and EGHS). In addition to this, the Medical Oncologist, Dr George Kannourakis, operates an extremely busy private practice in Ballarat but offers both public and private service to the Wimmera area in the absence of any regional oncology service provision from Ballarat Health Services. Cancer surgery, primarily for bowel, breast, prostate and bladder malignancy is provided at each of the three facilities. There is a Day Oncology Unit at each hospital for the provision of Cancer Chemotherapy and adjunctive therapy. WHCG Day Oncology is open four days per week (Tuesday to Friday) and EGHS and SRH one day per week (Wednesday only). The Medical Oncologist provides phone support to the staff on non visiting days. In 2011 there will be an additional Medical Oncologist joining the Ballarat private practice which will increase the visiting service to weekly at WHCG and subject to further recruitment the services at SRH and EGHS may increase to fortnightly. Some patients travel over 100 kilometres in one direction, from as far west as the South Australian border and as far north as Hopetoun for treatment. The patient numbers are increasing but the ongoing shortage of medical specialists to rural areas has stimulated the three organisations to create an alternative model to ensure sustainability. Gap analysis An analysis was conducted to identify the gaps in service according to key stake holders which mostly relate to the fact that there is no Medical Oncologist in the region. The oncology service is provided fortnightly at best which causes: High patient numbers on consulting days resulting in a heavy workload for the Visiting Oncologist, high staffing demands for Day Oncology units and lack of time for patient information Lack of continuity of care for patients at other times. Demand At WHCG the number of cancer chemotherapy and adjunctive treatments provided has increased 160% in 5 years from 733 treatments in 2004/05 to a projected figure of 1909 in 2009/10. At SRH the projected number of cancer treatments provided for 2009/10 is 640 and for EGHS 450, which makes a total of 3,000 treatments provided in the Wimmera area per year for patients who would otherwise be required to travel to Ballarat. It is anticipated that a highway model of care using an Oncology Nurse Practitioner can: Link the existing Oncology services and provide liaison with the Medical Oncologist Provide local clinical expertise in cancer care five days per week to the existing multidisciplinary team Provide consumers with timely access to information and co-ordination of care including follow-up and management of oncological emergencies Provide advanced skills and extended scope of practice to the nursing division Co-ordinate and provide education and clinical support to both Oncology and general nurses who care for patients with cancer. Wimmera Oncology Nurse Practitioner Model July 2010 3
Proposed Wimmera Oncology Nurse Practitioner Model Focus: The primary focus of the ONP is to provide continuity of care for oncology patients in the Wimmera through nurse lead clinics, telephone triage and liaison between the patient and the visiting Medical Oncologist (Appendix 1). The ONP will provide clinical leadership at a local level, review of patients with complex needs and timely management of symptoms, side effects and oncological emergencies. Table 1 Title EFT: Details 0.8 1.0 EFT Service Base Hours of service Patient Population: Referral criteria Service areas Clinical service offered Expanded scope of practice Key performance indicators Wimmera Health Care Group, Horsham Monday Friday; 08.30 1700 hours No out of hours service Cover - TBC Criteria A: Patients of WHCG, SRH &/or EGHC diagnosed with cancer and Criteria B: Patients with complex needs which may include one or more of the following: Significant physical symptoms of disease or treatment side effects Psycho /social issues Carer difficulties Use of more than three community service providers Attend clinics with VMO at WHCG, SRH, EGHS (Wednesday) Nurse lead clinics and telephone consults Potential for Nurse lead clinics at Nhill and Warracknabeal in the future Consultative service which may include: 1. Regular review of patients with complex needs 2. Initial patient consultations with VMO 3. Rapid response consultation; provision of rapid timely assessment for symptom management and oncological emergencies. Liaison with Medical Oncologist, GP &/or Emergency staff. 4. Counselling of newly diagnosed inpatients 5. Decision making support (treatment /end of life) 6. Insertion of PICC lines The NP will be competent to: 1. Prescribe medications within an approved formulary 2. Order appropriate investigations from pathology and radiology 3. Interpret results and manage treatment accordingly 4. Develop multidisciplinary evidence based clinical practice guidelines 5. Undertake procedures such as insertion of PICC lines 6. Refer to other Health care Professionals 7. Provide clinical leadership/education to nursing and junior medical staff 8. Undertake research and quality improvement 1. Timely assessment and management of symptoms and side effects to improve continuity of care and quality of life (Consumer satisfaction) 2. Reduced inpatient admissions for patients with complex needs 3. Increased skill set among Oncology and general nurses through clinical and professional leadership (Staff satisfaction) Wimmera Oncology Nurse Practitioner Model July 2010 4
NPC proposed weekly schedule Monday Tuesday Wednesday Thursday Friday AM Skill development MDM meeting Clinical Activities WHCG PM Education for Oncology nurses Case presentations for MDM Clinical Activities WHCG Telephone support VMO Clinic Dr Kannourakis VMO Clinic Dr Kannourakis Clinical activities SRH Clinical activities EGHS Professional development Professional development ONP Governance (Accountability) The collaborating organisations have introduced a Nursing Policy and Procedure to guide and support a streamlined and seamless integration of the NP role and expanded scope of practice into the nursing workforce of the Wimmera. The Wimmera Steering committee will continue with recruitment strategies and provide guidance and support for the ONP candidate when appointed. The ONP will work within a skill set of competencies for expanded scope of practice developed during the candidacy period and included in the position description. The skill set will be reviewed annually and updated in accordance with changes in: The requirements of the ONP role Evidence based oncology practice Technology Operational governance will be provided by the Nurse Unit Manager of the Day Oncology Unit at Wimmera Health Care Group with support from the Nurse Unit Managers at Stawell and Ararat. Professional governance will be provided by the Director of Clinical Services and clinically the ONP will be accountable to the Visiting Medical Oncologist. Clinical teaching will be provided by: The Visiting Medical Oncologist(s) Director of GICS (Medical Oncologist) Pharmacist Radiologist Medical registrars at WHCG General Practitioners The appointment of a mentor to guide the professional development of the ONP Candidate will be a collaborative decision following the appointment of a candidate in recognition of the importance of open communication mutual respect and trust. Risk assessment A risk assessment for the introduction and maintenance of the Wimmera ONP model has been conducted and tabled (Appendix 2). Strategies for risk mitigation are included and will be the responsibility of the Oncology Nurse Practitioner Steering Committee. Wimmera Oncology Nurse Practitioner Model July 2010 5
Appendix 1: Wimmera Oncology Nurse Practitioner Model July 2010 6
Appendix 2: Risk Management Description Impact Conse- Probability Score Strategy quence Recruitment unable to recruit ONPC ONP program not implemented High Possible High Promotion through three campuses Advertising CNSA website, newsletter and Conference Seek.com, Jobs for Nurses Grow our own long term plan Stakeholders lacking understanding of / commitment to program Inability of NPC to meet learning objectives in timely fashion Financial sustainability of ONP position- not funded through EBA and no funding for out patient clinics in region. Appropriate patients not identified &/or referred. NP not used as integral part of the Oncology team Delayed time to endorsement High Possible High Education and promotion of the role and benefits across organisations Referral criteria identified and publicised Ongoing consultation with key stakeholders Medium Possible Medium Links with metropolitan services Teleconferencing to Director of GICS Additional Visiting Medical Oncologist Defined program to include multidisciplinary teaching Loss of position High Possible High Shared cost between services commensurate with level of activity MOU between three organisations to include financial support commitment Scope of practice not aligned with service capability Patient safety compromised Medium Possible Medium Well defined model for advanced practice aligned to the capability of each Health service. Communication of the model to stakeholders within each of the participating Health services. Position descriptions developed for both NP Candidate and Endorsed NP common to all sites Limited access to NP for private patients Under-use of NP role Medium Possible Medium Promotion of Nurse lead clinic to consumers Clear referral channels for private and public patients Exposure of NP working across multiple sites NP/NPC not covered by Professional indemnity insurance High Unlikely Medium NPC and NP to be registered as an employee by each of the three health care facilities to ensure covered by organisational indemnity insurance Wimmera Oncology Nurse Practitioner Model July 2010 7