The Care Model

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The Care Model

• An NP/Physician collaborative model
• Acute Care Nurse Practitioner Model as Primary
  Care/ MRP
• Based on domains of advanced practice nursing
• Clinical Practice
• Education
• Research
• Administration

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• CARE Model a Collaborative Practice Model

Susan Whyte Acute Care Nurse Practitioner
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History

• 2004 Loss of general practitioner coverage at
  Lakeridge Health, Whitby
• 85 Complex continuing care/geri-rehab patients
  without primary care practitioner
• Innovative solution CARE Model

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CARE Model

• Based upon collaborative practice which includes
  both independent and cooperative decision-making
• Three Acute Care Nurse Practitioners, one
  Physiatrist
• Encompasses Advanced Practice Nursing domains
• - Clinical Care
• - Administration / Leadership
• Research
• Education

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Outcome Goals

• Timely effective comprehensive care
• Prompt response to changing clinical conditions
• Appropriate use of pharmaceuticals
• Improve patient / family satisfaction of care
  provided

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Hurdles Encountered

• Development of Medical Directives - A challenge
  unto themselves!
• Professional Practice Committee did not support
• Hospital legal council / HIROC
• Medical Advisory Council deemed the directives as
  too broad
• 52 attempts later the Medical directives were
  passed at Medical Advisory Committee

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Hurdles contd

• Turf preservation
• Key stakeholders MD, Nursing staff,
  Multidisciplinary team in particular
  Pharmacist
• We were Blessed!
• Then there was a fire.
• Then a move
• Pharmacist proven to be an integral part of the
  team

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Lakeridges Focus on Safety

• Admission through ER at Oshawa --gt
• Medication Reconciliation- streamline
  standardize the process of obtaining an accurate
  and up to date medication list
• Comprehensive medication review of all drugs
  taken prior to admission
• The ER Shoe Box Syndrome (aka brown bag or ziploc
  baggy in the purse)
• Same medication, generic form, multiple
  prescribers, different pharmacies

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Why use a Pharmacist?

• ID incorrect or fictitious dose
• Define allergy what were the clinical
  manifestations?
• Access to ODB list of meds
• Liaise with community colleagues

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General principals on the GARU

• Revisit the reason for admission
• Use a holistic interdisciplinary approach
• PT, OT and bedside nurse closest to the patient
• Visual deficits, illiteracy
• Functional Cognitive disabilities
• Safety concerns- choking, aspiration, dehydration
• Multiple comorbid conditions

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Prescribing Practices

• Geriatric Mantra start Low go Slow
• Clinical indications 2 for 1?
• Duration of treatment
• Use of current clinical practice guidelines
• Best Practice Guidelines
• Affordability

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Prescribing Practices

• Black Box warnings
• Weight, nutritional status (protein levels)
• Monitoring renal liver function, toxicology
• Drug-drug interactions
• Delirium
• Clostridium difficile risk

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Obstacles

• Belief system, patient and family
• Trust in family practitioner Mrs A
• Media reports / internet access
• Over reliance on pharmaceuticals

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Prior to Discharge

• Team review of the treatment plans
• What are the patient/ family concerns?
• Collaborative review of the medication regime one
  week prior to discharge
• Can anything be discontinued? Is there a clinical
  indication for the med?
• Patient and family education
• Review medications, administration time, dose,
  side effects
• Provide written schedule
• Encourage use of one pharmacy to fill all
  prescriptions

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The Reject File

• Review of medications with MD and NP only
• Sticking samples of meds on discharge MAR sheet
• Looking at labs ahead of time
• Medication / dose changes when writing discharge
  prescriptions
• Assumptions

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Summary

• Expanded Care team
• Combined knowledge and expertise
• Environment
• Patient Safety
• Team satisfaction