SYDNEY NURSING SCHOOL EVALUATION OF THE PRACTICE NURSE INCENTIVE PROGRAM IN NSW SUMMARY REPORT

SYDNEY NURSING SCHOOL EVALUATION OF THE PRACTICE NURSE INCENTIVE PROGRAM IN NSW SUMMARY REPORT

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3 Prepared for: The Australian Medicare Local Alliance Limited (AMLA) Authors: Christina Aggar PhD Christopher Gordon PhD Sydney Nursing School, The University of Sydney. Submission date: 30 th November Contact: Dr Christina Aggar Sydney Nursing School The University of Sydney T +61 2 9114 4191 E christina.aggar@sydney.edu.au

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5 Table of Contents Contents Abbreviations... 9 Operational Definitions... 10 Acknowledgements... 11 Commission... 11 Background... 13 Methods... 13 Summary of Findings... 15 Recommendations... 17 Practice-orientated category recommendations... 18 Recommendation one... 18 Recommendation two... 19 Recommendation three... 20 Practice Nurse-specific category recommendations... 20 Recommendation four... 21 Recommendation five... 21 Recommendation six... 21 Recommendation seven... 22 Recommendation eight... 22 PNIP awareness recommendations... 23 Recommendation nine... 23 Recommendation ten... 24 Recommendation eleven... 24 Conclusion... 24 References... 26

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9 Abbreviations Acronym Explanation AAPM Australian Association of Practice Managers ACCHS Aboriginal Community Controlled Health Services AMLA Australian Medicare Local Alliance APNA Australian Primary Health Care Nurses Association CCNSWML Central Coast NSW Medicare Local ESML Eastern Sydney Medicare Local GP General Practitioner IWSML Inner West Sydney Medicare Local MBS Medicare Benefit Schedule ML Medicare Local NIGPI Nursing in General Practice Initiative NP Nurse Practitioner NSML Northern Sydney Medicare Local NSW New South Wales PMgr Practice Manager PN Practice Nurse PNIP Practice Nurse Incentive Program RACGP The Royal Australian College of General Practitioners RCNA Royal College of Nursing RN Registered nurse SWSML South Western Sydney Medicare Local WML Western NSW Medicare Local

10 Operational Definitions For the purpose of this report, the following operational definitions were adopted: Term General practice PNIP-Users Practice accreditation Practice Nurse Practice Manager Explanation The provision of patient centred continuing, comprehensive, coordinated primary care to individuals, families and communities, as defined by the Royal Australian College of General Practitioners: Standards for general practices (4th Ed). East Melbourne, VIC: The Royal Australian College of General Practitioners;. General practices that were employing one or more practice nurses and claiming the PNIP-incentive at the time of data collection for this study (August - October ) Accreditation of general practices against the quality and safety Standards for General Practices issued and maintained by the Royal Australian College of General Practitioners Department of Health and Ageing. Medicare Benefits Schedule Book. Canberra, ACT: Department of Health and Ageing,; 2011. A registered or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice NB: For the purposes of this report, we are retaining and consistently using the term Practice Nurse despite the Australian Practice Nurses Association (APNA), the peak professional body representing practice nurses in Australia, having replaced this term with the new title Primary Health Care Nurse. APNA defines the latter as enrolled nurses, registered nurses and nurse practitioners eligible for registration by the Australian Health Practitioner Regulation Agency whose competence, as specified by the registering authority s license to practice, educational preparation, relevant legislation, standards and codes is specific to (though not exclusive to) the primary health care context. Definition of primary health care nursing, http://www.apna.asn.au/scripts/cgiip.exe/wservice=apna/ccms.r?pageid =11012. Accessed 6 th November. A person employed by general practice whose primary role may include the financial management, human resource management, planning marketing, and risk management of the general practice.

11 Acknowledgements We sincerely thank: AMLA for commissioning us with the project and providing valuable background information, NSML, IWSML, SWSML, ESML, WML and CCNSWML for assistance with recruitment of project participants for focus groups, distributing questionnaires and providing local background information AAPM and APNA for assisting with the distribution of questionnaires to PNs and PMgrs and for providing profession-specific background information Thanks also go to all project participants who generously shared their personal perspectives on the PNIP with us. Commission The Sydney Nursing School, University of Sydney was commissioned to undertake a consultancy related to the PNIP uptake in NSW. The initial project was scoped to determine stakeholder opinions predominately using focus groups. However, in the course of the consultancy we had a large response to survey data and focus group size and numbers. Accordingly this report will detail the responses from approximately 400 health professionals from NSW. It should be noted that the findings only relate to PNIP uptake in NSW and a National evaluation is currently underway.

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13 Background In January 2012, the Australian Government introduced the Practice Nurse Incentive Program (PNIP), an initiative that provides incentive payments to general practices to support an expanded and enhanced role for Practice Nurses (PN). In addition to expanding and enhancing the role of PNs to benefit both general practice and patient health outcomes, it was anticipated that the PNIP would result in an increase in the number of PNs employed in general practice. However, anecdotal evidence suggests that barriers to the uptake of the PNIP exist. This prompted the Australian Medicare Local Alliance (AMLA) to contract Sydney Nursing School, at The University of Sydney to evaluate and ascertain significant barriers to the PNIP in New South Wales (NSW). Methods The project key stakeholders included General Practitioners (GPs), Practice Nurses (PNs) and Practice Managers (PMgrs) working in general practices in metropolitan and rural NSW. We surveyed and interviewed GPs who were PNIP-users and non-users and general practices that were RACGP accredited and non-accredited practices. To adequately evaluate the PNIP across NSW within the allocated timeframe we engaged with five metropolitan Medicare Locals (Northern Sydney ML, Inner West Sydney ML, Eastern Sydney ML and Sydney South West ML, Central Coast NSW ML) and one rural Medicare Local (Western ML). In addition, we have consulted with professional primary care stakeholder bodies including the Australian Primary Health Care Nurses Association (APNA) and the Australian Association of Practice Managers (AAPM). The project design included a qualitative and a quantitative component, which were implemented in parallel. In the qualitative stream, we conducted face-to-face semistructured focus groups and one-on-one interviews with GPs, PMgrs and PNs. In the quantitative arm of the project, we designed three separate questionnaires for GPs, PMgrs and PNs respectively. Each questionnaire was developed in two formats, a paper-based and an online version for distribution through online software.

Quantitative data comprised of 351 returned questionnaires from metropolitan and rural general practices. Qualitative data was collected from six focus groups, one on one interviews and the questionnaire open-ended questions. 14

15 Summary of Findings This report identified a number of key findings related to barriers of the PNIP uptake across metropolitan and rural settings. The barriers are reflected in the following four themes: a. General practice characteristics that influence the PNIP; b. Awareness of the PNIP; c. Impediments to the PNIP uptake, and, d. Benefits to the PNIP implementation. Characteristics of the general practice that influence the PNIP There was a positive relationship between the number of GPs and the number of PNs employed under the PNIP in any one general practice; the larger the practice, the more PNs employed; There was a significant association between PMgr and PN employment under the PNIP; 93% of PMgrs stated that their practice employed at least one PN; On average, three times more PNs were employed in rural general practices compared to metropolitan practices; Non-accredited practices were more likely to be smaller and unlikely to employ a PN and therefore less likely to apply and implement the PNIP; GPs in metropolitan settings were more likely to work in a solo or dual GP practice compared to GPs in rural settings who were more likely to work in practices with more than 3 GPs; Older GPs were more likely to work in smaller practices; as the age of the GP decreased, the number of GPs employed in the practice increased; Awareness of the PNIP Over half (53%) of GPs surveyed were not using the PNIP and 47% of those not using the PNIP were not aware of the initiative program. Only a third of the GPs who were not aware of the program wanted more information about the PNIP; Eight five percent of GPs whose practice was not accredited were not aware of the $5000 incentive payment linked to the PNIP to assist with the accreditation process.

16 Impediments to the PNIP uptake High practice rent expenses and limited space availabilities are a major barrier for small practices (i.e. solo or dual practices) in Metropolitan Sydney to accommodate a PN; GPs working in solo or dual practices in metropolitan Sydney reported limited or no administrative support or own time availabilities to investigate the details of the PNIP; GPs have expressed concerns regarding sourcing a PN with the qualifications required to work in general practice; GPs from smaller practices found accreditation, recruitment and training of PNs a lengthy process; Several GPs from small practices who did not employ a PN were concerned of the potential negative patient perceptions of PNs; The introduction of the PNIP and the removal of several MBS billing item numbers meant that PNs were no longer able to consult with patients independently. Benefits to implementing the PNIP PNs employed under the PNIP performed a greater number of roles on average compared to those not employed under the PNIP; PNs employed under the PNIP were significantly more likely to conduct Wellness Clinics, Care Coordination and Chronic Disease Management; Facilitators of the uptake of the PNIP include the employment of a PMgr, the rural location of practice and the involvement of GPs; Employment of a PN under the PNIP increases the range of services the general practice delivers, which can provide an alleviation of patient waiting times, which in turn leads to higher levels of patient satisfaction.

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18 Recommendations The recommendations set out in this report have been constructed to increase the PNIP participation in NSW general practices with an emphasis on metropolitan practices. This was determined to be the most urgent of need. The evaluative component of the report demonstrated clear PNIP inequities between general practice size and location, PMgr involvement, defined PN roles, and awareness of the PNIP by GPs. For the moment, it appears that most stakeholders interviewed were positive about the PNIP but there was some dissatisfaction in a minority about the changes to the PN funding. These predominately focus on the removal of the six MBS billing items and this often coincides with the general practice s management of PN activities. This report s recommendations are grouped using three categories, namely: 1. general practice needs; 2. Practice Nurse needs; and, 3. raising awareness of the benefits of the PNIP. It should be noted that these recommendations were not discussed in detail with the stakeholders. The formulation of these categories were developed following data and thematic analysis when the major findings were identified. However, a general discussion of some of the recommendations were proffered with some stakeholders who aided in informing the finalisation of these recommendations. Practice-orientated category recommendations The following recommendations are designed to target general practices that have either not employed a PN or have one (may consist of two or more PN working as one full-time equivalent) PN currently employed. Recommendation one The development of a General Practitioner Champion initiative that promotes the benefits of the PNIP to GPs not currently utilising the program. It was evident from the focus groups and one-on-one interviews that there were a number of GPs who are strong advocates of the PNIP and PN roles in general practice. At

GP focus groups, numerous discussions arose between GPs about the benefits of PNs and how to fully use the PNIP. Therefore, the genesis for this recommendation evolved as result of the enthusiasm of the GPs who used the PNIP and addresses the apprehension of some GPs that the PNIP would not benefit their general practice financially or clinically. 19 The GP-Champions would work to inform GP networks about the PNIP. The GP Champions would need to be identified through the Medicare Local network. The advantage of using a GP champion is that it would form a peer-to-peer system with other GPs and would not appear top down. It is envisaged that the Medicare Locals would facilitate this process, possibly through the regular meetings with GPs but also through formal workshops. This may encourage GPs who may be considering employing a PN to attend and understand practical aspects of the PNIP and PN roles within current successful practices. The GP-champions would discuss their models of PN employment in a workshop forum or round tables. Specifically, it is recommended that the target audience would be GP principals. Recommendation two The development of a Practice Manager Champion initiative that facilitates the GP champion regarding the benefits of the PNIP to GPs who do not currently utilise the program. Evidence from the questionnaires and focus groups established that PMgrs appear to be the drivers of the PNIP uptake in general practices. Additionally, PMgrs are integral to the accreditation process and so it would appear prudent to have PMgr Champions discuss the PNIP benefits with GPs who want to employ a PN. This initiative would work in a similar guise to the GP Champion model. The PMgr Champions would need to be identified through the Medicare Local network. Practice Manager Champions would work alongside the GP Champions in workshops/roundtables conducted by the Medicare Locals. In this way, the PNIP Champion workshops would provide a comprehensive overview of the clinical and

20 financial benefits of the PNIP. This initiative would utilise the skills and knowledge of PMgrs to better inform GPs on how to successfully utilise the PNIP. This was evident from the workshops attended by GPs and PMgrs together, when GPs wanted information about the detailed costings of the PNIP. This demonstrated that the financial knowledge of the PNIP was predominately with the PMgrs. The workshops should involve viable business models, i.e. how practices can financially benefit from PNs in addition to the annual PNIP payments Recommendation three Development of GP and PMgr Champion workshops to facilitate meetings for GPs who do not currently utilise the PNIP and want to employ a PN. As outlined above, the Medicare Local would be central to the coordination of these workshops. The consultation recognised that Medicare Locals currently have a number of workshops for general practices on a variety of topics and this workshop series would be incorporated into the current structure. The recommendation further suggests that a centralised workshop program related to the PNIP is developed by Australian Medicare Local Alliance. This would entail information about the clinical and financial aspects of the PNIP and how it aids in developing the PN role in practices that do not currently employ a PN. The Medicare Locals through the GP and PMgr Champions would run the workshops. Practice Nurse-specific category recommendations The following recommendations have been designed specifically for PNs, to increase and develop the role of the PN. During the consultancy it became abundantly clear that despite some increases in scope of practice of PNs and the number of PNs employed, there remained a shortfall of qualified PNs. Moreover, role limitations remained. The following recommendations address these limitations and how the inclusion of the PNIP can be used as a mechanism to facilitate these changes.

21 Recommendation four The development and implementation of a transition-to-practice (new graduate) year for graduating nurses. The targeting of newly graduated registered nurses should be considered a priority for the development of the practice nurse profession, and the PNIP could greatly facilitate this process. Currently in Australia, the majority of new graduate nurses commence work in the acute care sector in hospitals. Over time, hospitals have developed transition-to-practice (commonly referred as new graduate programs), providing nurses with structured support related to clinical education in their first year of practice. The programs have been successful as a recruitment tool and in some ways provide the hospital with a way of attracting stronger graduates with better academic grades. Discussions with many current PNs revealed a deficiency in the current system for the transitioning of nurses from the acute care sector to the primary care setting. This recommendation would assist in addressing this current limitation. Accordingly, we suggest the development and implementation of a transition-to-practice (new graduate) year for graduate PNs with a structure similar to that of the hospital system. This supports recruitment, induction and retention of PNs. Recommendation five Developing and fostering PN autonomy within general practice. The most common complaint across all stakeholders was that the PNIP had reduced PN autonomy. The development of strategies to increase PN autonomy should be explored. Recommendation six Funding stream to support training and up-skilling for existing PNs. There is considerable scope to enhance educational opportunities related to training, skill development and professional support for PNs. Currently, there are a range of educational opportunities for PN, ranging from APNA-supported continuing professional

22 development to postgraduate Master degrees. Evidence from the consultancy indicates that there has been a paucity of educational opportunities for PNs, particularly advanced degrees, such as coursework Masters. With the expansion of educational opportunities, it is recommended that PNs be provided with funding opportunities for furthering education. There are a number of universities, including the contracted one, that have post-graduate primary health care degrees which are ideally suited for PNs. In coordination with the PNIP, increasing PN qualifications is a desirable outcome. This is likely to improve patient outcomes. Funding opportunities that enhance PN s professional scope of practice would be desirable. Recommendation seven Promote the patient-centred and financial benefits of nurse-led chronic disease management clinics. PNs and GPs interviewed in focus groups and one-on-one interviews spoke highly of nurse-led chronic disease management clinics. The PNIP was integral to the continuation of these clinics, although MBS billing items claimed as part of this process were financially attractive. Nevertheless, these clinics enhanced the PN s scope of practice and enhanced patient-centred care. It is recommended that partnerships and collaborations between researchers and practitioners are developed to establish initiatives that address chronic disease prevention. Further research of nurse-led clinics is therefore recommended. Recommendation eight Develop partnerships and collaborations between researchers and health care practitioners to establish evaluative processes that focus on the role of the PN in primary care. It is recommended that collaborations and partnerships are fostered between health care practitioners and researchers. There are a number of existing research collaborations; however, rigorous empirical evidence to support the role and scope of

23 practice of PNs are required. Practice nurses need to be involved in the research collaborations and this will further enhance PN leadership capacity. PNIP awareness recommendations The final category of recommendations are intended to raise awareness of the PNIP. This should be directed at specific general practices that have shown interest in the PNIP and would benefit from the information. The consultancy process revealed that despite a concerted and comprehensive information campaign promoting the PNIP by AMLA, this was not universally received by GPs and practices and many GPs revealed that they were unaware of the program. Several GPs indicated that they would like further information about the PNIP. The following recommendations have been constructed to assist with raising awareness of the PNIP, especially the benefits related to the employment of a PN. Recommendation nine Target medium-size general practices who do not currently employ a PN and provide information about the benefits of the PNIP. In light of the findings that half of GPs at medium sized practices (3-5 GPs) were unaware of the PNIP, these practices should be targeted and provided information about PN roles and the benefits of utilising the program. It was determined that this group would most likely embrace the program if they had more information about the PNIP. Specifically, the financial aspects of the PNIP and the roles of the PN need to be conveyed. The use of GP and PMgr Champions would be central to this campaign. General Practitioners in small general practices and older GPs would be the least likely to want to introduce the PNIP in their practice; however, they should not be excluded. A small number of solo GPs did employ a PN and were using the PNIP.

24 Recommendation ten Promote awareness of Medicare Locals role in assisting general practices with the accreditation process. There was considerable discussion from the focus groups about RACGP accreditation processes and the impact on the general practice. Many general practices found the process burdensome and others chose simply not to undertake accreditation. It was clear that a substantial amount of accreditation support is made available by the Medicare Locals and awareness of this supports needs to broaden. Awareness programs targeting general practices that are not accredited are warranted. Moreover, incorporating AAPM would likely benefit this process as evidence from the consultancy suggests that PMgrs were central to the accreditation process. The accreditation assistance offered through the PNIP (one-off $5000 payment) would financially assist those general practices. In general practices without a PMgr, the payment may assist with PMgr costs. Recommendation eleven Increased use of the Primary Care Infrastructure Grant scheme, which provides funds to practices to expand their existing premises. The grants offer up to $500,000 to expand existing premises and opening hours, improve access to services and develop new training facilities 1. Knowledge of the Primary Care Infrastructure Grant projects in -2014 2 may encourage and benefit smaller practices that are interested in the PNIP but do not have the physical space, especially in Metropolitan areas. Conclusion In summary, larger general practices, defined as practices that employ more than 6 GPs, are more likely to utilise the PNIP and employ PNs. This was typically related to the employment of a PMgr, who was intricately involved in the initial and ongoing accreditation process and PN employment using the PNIP. General practitioners who worked in metropolitan areas

25 were more likely to be older (>55 years) and be in small general practices and not be utilising the PNIP. Interestingly, rural general practices were often larger, with a greater number of GPs and PNs compared to metropolitan practices. In addition, general practices that employed a PMgr, irrespective of practice size, were more likely to utilise the PNIP and employ at least one PN.

26 References 1. Health AGDo. Primary Infrastructure Grants. Programs and Campaigns. 2. Health AGDo. Primary Care Budget Statements. Canberra: Australian Government;.