Ministry of Health and Long-Term Care Attending Nurse Practitioners in Long-Term Care Homes Initiative Round 2 Implementation Guidelines Nursing Policy and Innovation Branch, Ministry of Health and Long-Term Care October 2016
Ministry of Health and Long-Term Care
Table of Contents Program Overview... 4 Summary of Changes to Selection Process... 5 Implementation Approach... 5 Selection Process... 6 Selection Criteria... 7 LTCH Integration Plan... 8 LHIN Recommendations... 9 Appendix A Attending NP Role Description... 10 3
Program Overview The Attending Nurse Practitioners in Long-Term Care Homes (Attending NPs in LTCHs) Initiative is part of the government s plan to build a better Ontario through its Patient s First: Action Plan for Health Care. The plan provides patients with faster access to the right care, better home and community care, information they need to stay healthy, and a health care system that s sustainable for generations to come. Building on the success of the NP in LTC Pilot, the initiative will fund 75 Attending Nurse Practitioner (NP) full-time equivalents (FTEs) in LTCHs over three years. As the most responsible provider with overall responsibility for the management and coordination of care for residents in the LTCH, the Attending NP will help increase access to, and quality of, primary health care by providing proactive screening and assessment, timely specialist referrals, follow-up care, ongoing chronic disease management, and end of life care. The Attending NP will be an onsite provider and will use 70% of his/her time to provide direct care to residents, and the remaining 30% of time for education, quality improvement, research, and leadership activities. The Attending NP will contribute to: Continuity of care; Creation and implementation of Quality Improvement Plans; Research and implementation of evidence-based practices; Increased knowledge capacity of staff and programming in the LTCH to meet the needs of residents; Improved care coordination and collaboration across the care continuum among health care providers within the LTCH and in the region; and Internal and external committees on behalf of the LTCH. 4
Summary of Changes to Selection Process Based on lessons learned and health partner input from Round 1, several changes are being implemented in the selection process for Round 2: A longer selection process, approximately six weeks, will allow more time for Local Health Integration Networks (LHINs) to work with their LTCHs and for LTCHs to develop their Integration Plans. A single Integration Plan will be accepted from LTCHs that are sharing a position (approved by representatives from both LTCHs). The Medical Director of the LTCH will sign off on behalf of the attending physicians of the LTCH, indicating the medical team s support for the role. LHIN recommendations for the selected LTCHs will be submitted in a standardized format, which will describe the LHIN s rationale for its selections and how the LHIN will support the Attending NP role. Implementation Approach LHIN Long-Term Care (LTC) Leads will collaborate with the Ministry of Health and Long-Term Care (the ministry ) Service Area Office (SAO) Managers to select LTCHs (or LTCH pairs) to implement 30 Attending NP FTEs, starting in fiscal 2016/17 (see Appendix A Attending NP Role Description for information on the Attending NP role). Based on the selection criteria (see Selection Criteria on page 7 for details), the LHIN LTC Leads will provide the ministry with a short-list of five LTCHs (or LTCH pairs) and recommend two LTCHs (or LTCH pairs) per LHIN to receive Attending NP services. Two LHINs will receive three Attending NPs, and, therefore, will recommend three LTCHs (or LTCH pairs) to receive services. 5
Selection Process Activity 1. The Nursing Policy and Innovation Branch of the ministry will meet with the LHIN LTC Leads and SAO Managers to discuss the selection process and criteria. LTCHs will be informed by their LHIN, in a communication that will provide details of the selection process and related criteria. LTCHs will have the opportunity to express their interest to the LHIN. 2. LHIN LTC Leads will use the selection criteria to identify up to five LTCHs (or LTCH pairs) for consideration to receive Attending NP services. LHINs will provide the list to their local SAO Manager for input on the home s compliance status and history, as well as its operational and management capacity to fully utilize the services of an Attending NP. 3. LHIN LTC Leads will ask the identified LTCHs (or LTCH pairs) to complete the LTCH Integration Plan Template. The template must be signed by the LTCH s Board, Medical Director (also on behalf of attending physicians) and Administrator and/or Director of Nursing and Personal Care committing to the integration of the Attending NP role responsibilities as outlined in the Attending NP Role Description. 4. LHIN LTC Leads will review the LTCH Integration Plan Templates and identify LTCHs (or LTCH pairs) to receive Attending NP services (two or three depending on allocation). This will be discussed with the relevant SAO Manager. LHIN LTC Leads will document their rationale for selection and identify any supports to be provided for recruitment and optimization of the Attending NP role. It is strongly recommended that bargaining unit representatives be contacted for any unionized LTCHs under consideration to identify any concerns. 5. LHIN LTC Leads will send their LTCH recommendations, selection rationale and all documentation pertaining to the top five LTCHs to the Nursing Policy and Innovation Branch at nursing@ontario.ca. Anticipated Timing for Completion Week of October 11 th Two Weeks Three Weeks One Week November 28, 2016 6
Selection Criteria The LHIN LTC Leads and SAO Managers will work together to identify LTCHs (or LTCH pairs) to receive services, that meet the following criteria: 1. LTCHs with a projected or demonstrated gap in access to care o LTCHs that are lacking health care providers who: Provide on-site comprehensive resident care as most responsible provider (not solely responding to acute or episodic changes in condition); Provide ongoing resident care that is coordinated within the continuum of care; Order diagnostic investigations, interpret results, and assume responsibility for follow-up; and Diagnose and manage acute and chronic health conditions. 2. LTCHs demonstrating need for quality improvement o LTCHs whose reporting history and Quality Improvement Plan suggest that they would benefit from the quality management and clinical support of an Attending NP in resident care areas such as: Skin and wound care; Falls management; Continence care; Behavioural supports; and Unique/challenging individual resident care profiles. o o LTCHs that are lacking health care providers who provide formal and informal teaching and coaching in the management of clinical care to interdisciplinary team members. LTCHs whose stability in general operations suggest that implementing an Attending NP would enhance their quality management structure and, in turn, that the Attending NP would receive sustainable support from management. 3. A Caseload of Up to 175 Residents o A caseload of up to 175 residents for one Attending NP FTE was recommended by members of the Attending NP Role Development Task Force, who were responsible for developing the role responsibilities of the Attending NP. 7
The ministry will review the rationale for the recommended LTCHs (or LTCH pairs), provided by the LHIN. The LHIN s rationale for selection should demonstrate the readiness for and acceptance of the Attending NP role by the LTCHs. In this regard, the LHIN should also consider the LTCH s human resource infrastructure, continuing education resources, and research capacity. LTCH Integration Plan The LHIN LTC Leads will ask their top five LTCHs (or LTCH pairs) to complete the LTCH Integration Plan Template. The purpose of the plan is to provide the LHIN and ministry with an overview of the LTCH s stated need for an Attending NP and its proposed approach to achieving key milestones with respect to the integration of the Attending NP role. The Integration Plan Template will provide details related to: Recruitment of the Attending NP, including the human resource capacity of the LTCH; Orientation and integration of the Attending NP in the LTCH; Infrastructure in place to support the Attending NP s role in resident care and leadership activities; Clinical coverage plan related to resident needs that require physician care; Plan to integrate resident care provided by the Attending NP with other health care providers within the LTCH and in the region; and Sharing of the Attending NP between two LTCHs (if applicable). Completed Integration Plans must be signed by the LTCH s Board, Medical Director (also on behalf of attending physicians), and Administrator and/or Director of Nursing and Personal Care committing to the integration of the Attending NP role responsibilities as outlined in the Attending NP Role Description. Based on the five Integration Plans received, the LHIN will select two (or three, as applicable) LTCHs (or LTCH pairs) to receive Attending NP services. 8
LHIN Recommendations In order to clarify the selection process undertaken by LHINs, each LHIN will be asked to provide a summary document explaining its process and rationale for selecting the short-listed LTCHs and the two (or three, as applicable) LTCHs (or LTCH pairs) recommended to receive Attending NP services. This summary document should describe: The suitability and readiness of the recommended LTCHs to implement the Attending NP role, based on deliberations between the LHIN and SAO Managers, as well as other considerations in making the selections (e.g., application of selection criteria); Any potential issues with the selections (e.g., lack of professional or clinical supports) identified by the LHIN and/or SAO Managers, and how the LHIN plans to mitigate these concerns (e.g., through local resources, such as Nurse-Led Outreach Team supports); and How implementation of the Attending NP role by the recommended LTCHs will support the LHIN s plans for its local health system, including quality improvement and enhanced LTCH capacity. 9
Appendix A Attending NP Role Description Role Description for Attending Nurse Practitioners in Long-Term Care Homes Position Summary The Attending Nurse Practitioner (Attending NP) reports directly to the Director of Nursing and Personal Care and is also accountable to the Medical Director for meeting the Long-Term Care Home s (LTCH) policies, procedures, and protocols for medical services. The Attending NP is a primary care provider to residents and works within her/his legislative scope of practice as described and outlined by the College of Nurses of Ontario. The Attending NP collaborates with the resident and family/care giver, and the health care team in the development, implementation and evaluation of the resident s plan of care; provides leadership and mentorship to LTCH staff 1 that enhances their knowledge, assessment skills, and ability to care for residents in place; and leads and collaborates in research, education, and evidence-based practice initiatives to optimize the resident, LTCH and health system outcomes. Qualifications Current registration with the College of Nurses of Ontario as a Registered Nurse in the Extended Class (Primary Health Care or Adult) and entitled to practise Post-graduate education and experience in gerontology (an asset) Specialty certification in gerontological nursing (an asset) Post-graduate certificate and experience in palliative care (an asset) Accountabilities The NP: Maintains confidentiality and acts in an ethical manner, consistent with professional expectations, the written agreement between the NP and the LTCH, and the LTCH s policies and code of conduct. 1 The Long-Term Care Homes Act, 2007 defines staff as follows: staff, in relation to a long-term care home, means persons who work at the home, (a) as employees of the licensee, (b) pursuant to a contract or agreement with the licensee, or (c) pursuant to a contract or agreement between the licensee and an employment agency or other third party; ( personnel ) 10
Is a member of the primary care team and seeks appropriate consultation as required. Engages in ongoing professional development, maintains clinical competence and currency with legislation affecting her/his practice. 2 Develops in-depth expertise in care of older persons. Develops in-depth expertise in leadership. Holds professional liability protection. Maintains CPR certification designed for health-care professionals and standard first-aid. Roles and Responsibilities 70% Direct Care to Residents 3,4 ( Attending NP ) 1. Provides comprehensive primary care to residents 5 as part of the interdisciplinary health care team. 6 2. Increases continuity of care through collaboration, consultation and referral 3, 4 as appropriate: a. Collaborates and consults with physicians, director of nursing and personal care, nursing staff, interdisciplinary team members and external resources regarding resident plan of care. b. Assists, supports, guides and provides consultation to director of nursing and personal care, nursing staff and interdisciplinary team members regarding challenging clinical situations. c. Makes referrals to specialized consultants, services and other health providers. d. Accepts referrals from interdisciplinary team members. 3. Performs a person-centered health assessment of residents on admission, annually and as needed (including quarterly medication reviews). 4. Conducts person-centered comprehensive health histories. 5. Engages with the resident in regular dialogue about their care plan. 6. Participates in regular care conferences. 7. Orders and/or performs appropriate screening and diagnostic investigations, interpreting results and assuming responsibility for follow-up. 4 8. Diagnoses acute and chronic health conditions. 2 College of Nurses of Ontario (Revised 2011). Nurse practitioner, practice standard. Retrieved from www.cno.org 3 Donald, F. and Martin-Misener, R. (2011, August). Understanding the individual, organizational, and system factors influencing the integration of the nurse practitioner role in long-term care settings in Canada. Retrieved from www.ryerson.ca/apnltc/finalreport.pdf 4 Canadian Nurse Association (2010, May). Canadian nurse practitioner core competency framework. Retrieved from http://www.cnaaiic.ca/cna/documents/pdf/publications/competency_framework_2010_e.pdf 5 Resident includes substitute decision makers as appropriate. 6 Interdisciplinary health care team includes unregulated health care providers. 11
9. Manages the care of residents by providing pharmacological, complementary and/or counselling interventions, and performs procedures within the NP scope of practice. 10. Advocates for and provides palliative and end-of-life care. 11. Documents clinical data, assessment findings, diagnoses, plans of care, therapeutic interventions, resident responses and clinical rationale in a timely and accurate manner. 12. Utilizes communication and counselling skills 3 a. Engages residents in dialogue to determine what is important to them for health and quality of life. b. Provides person-focused health education. 13. Collaborates with the resident to develop a person-centered plan of care. 14. Provides outreach and transitional services to LTCH residents who return to the community. 15. Liaises with discharge planning services for hospitalized residents to ensure a smooth transition back to the LTCH. 16. Participates in providing after hours and on-call coverage in accordance with the on-call policy of the LTCH. 30% Research, Education, and Leadership 3,4 1. Participates in creating an organizational environment that supports the safety quality of resident care and life, collaborative practice, and professional growth. 4 2. Participates in internal (e.g. Professional Advisory Committees, Quality Committee) and external committees. 3. Identifies, develops and implements practice innovations, in collaboration with the LTCH s senior leadership team. 4. Provides leadership and involves the interdisciplinary team in quality improvement initiatives. 5. Provides leadership in developing and implementing strategies to optimize the integration of illness and injury prevention, health promotion, health maintenance, rehabilitation and restorative care activities. 6. Participates with the senior leadership team in program planning to meet the needs of short and long-term residents and of residents of varying age groups. 7. Teaching and coaching 3 a. Provides formal and informal teaching and coaching in the management of clinical care to interdisciplinary team members, serving as resource person, educator and role model and contributes to the performance appraisals of registered nursing staff. b. Participates in identifying, analyzing and interpreting trends in resident care outcomes and professional nursing practice issues to determine priorities for educational programming. c. Contributes to planning, implementing and evaluating learning resources and health education programs for residents, families and substitute decision makers. 12
d. Promotes knowledge development of clinical staff by integrating best practices in resident care. 7 8. Research 4 a. Engages in evidence-informed practice by critically appraising and applying relevant research, and theory in providing health-care services. 4,7 b. Identifies and implements research-based innovations for improving resident care. 4 c. Collaborates with members of the interdisciplinary team and/or community to identify research opportunities and to conduct and/or support research. 4 d. Acts as a change agent through knowledge translation and dissemination of new knowledge that may include formal presentations, publications, informal discussions, the development of best practices, policies and procedures. 4,8 7 Registered Nurses Association of Ontario (2014, March) Nursing Best Practice Guidelines. Retrieved from http://rnao.ca/bpg 8 Aestima Research (2002, February). The Ontario nurse practitioner in long-term care facilities pilot project-interim evaluation. Retrieved from http://www.health.gov.on.ca/en/common/ministry/publications/reports/nurseprac02/nurseprac02_mn.aspx 13