Comprehensive

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners
Alba DiCenso, RN, PhD Professor, Nursing
Clinical Epidemiology Biostatistics McMaster
University CHSRF/CIHR Nursing Chair in Advanced
Practice Nursing
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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• What do we know?
• What factors support NP integration?
• What challenges do we face?
• How can we address the challenges?

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• What is a Primary Health Care
• Nurse Practitioner?
• An RN with advanced education and competencies
  to
• Provide health promotion and preventive care
• Diagnose treat minor illnesses injuries
• Manage stable chronic diseases

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• NPs in US, Australia, UK, and New Zealand
• Northern Canada since early 1970s
• Work in traditional community-based primary care
  settings and LTC, EDs public health
• About 900 licensed NPs in Canada (CIHI 2005)

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Canadian Nurse Practitioner Initiative
• Funded by Health Canada for 8.9 million from
  2004 2006
• Develop a framework for the integration
  sustainability of the NP role in Canadas health
  system
• 5 working groups
• Legislation regulation
• Practice evaluation
• Education
• Health human resources planning
• Marketing communication

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• NP Contribution to Comprehensive PHC
• Illness and injury prevention
• Early detection
• Health promotion
• Management of stable chronic illness

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Factors Supporting Integration
• Widespread political support
• Need for role shortage of MDs, increasing
  prevalence of chronic diseases
• All provinces or territories in Canada either
  have NPs or are currently tabling legislation

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Factors Supporting Integration
• Autonomous practitioners with liability
  protection
• Most provinces have educational programs to
  prepare NPs
• Current emphasis on multidisciplinary teams
  interprofessional education

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Most Evaluated Member of Health Care Team
• Systematic review (Horrocks, BMJ, 2002) of 11
  RCTs found no difference in patient health
  status, increased patient satisfaction, and some
  evidence of improved quality of care

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• CHSRF Mythbuster (2002)
• research clearly and consistently demonstrates
  NPs can provide care that is safe, effective, and
  comparable (to MDs) in a range of situations. The
  few remaining barriers to best realizing the
  benefits of NPs may be found in the structure of
  the system itself, such as payment models and
  funding mechanisms

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Benefits of NPs (MDs currently working with NPs)
• (n 225 43 response rate)
• NP can focus on patient education 90
• NP can focus on wellness 89
• NP can focus on specific patients 87
• NP can link with community resources 85
• MD can focus on more acute cases 85
• Practice sees more patients 79
• Reduces MD workload 75

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• MD satisfaction with NP role (n 225 43
  response rate)
• Quality of care provided 92
• Consult with MD when appropriate 90
• Length of time spent with patients 81
• MD ability to access NP services 79
• Time NP spends documenting 77
• Time required to support NP 75

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Factors Supporting Integration
• Political Support v
• Evidence v
• Need v
• Training Programs v
• Legislation/Regulation v
• Liability Coverage for NPs v
• Current Emphasis on Teams v

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Challenges to Integration of NPs
• Funding of NPs
• Need earmarked funding for NP positions
  independent of MD remuneration
• FFS practice (42 interested in working with NPs)
• ED physicians (61 interested in working with
  NPs)
• LTC physicians (80 interested in working with
  NPs)
• Funding for NP-related overhead, start-up
  orientation costs MD time spent consulting with
  NP

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Regulatory Legislative Barriers
• E.g., Public Hospitals Act
• Prescriptive Diagnostic Authority varies by
  province
• in Ontario, regulatory process currently required
  to update list of drugs diagnostic tests
• Other jurisdictions in Canada have chosen to
  grant broader authority

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Specialist Billing
• Today I called a gynecologist to refer a client.
  They said they needed a family physicians
  referral. I told them the client did not have a
  family physician which is not unusual in this
  community so they told me the client would have
  to go to emergency to get a referral. That means
  the client was required to make two visits for
  the same problem. Does that sound efficient to
  you? (NP)
• One thing that irritates me about working with
  the NP is the need for us to sign for their
  referrals to specialists. For many clients it is
  a straightforward decision but if I have to sign
  for this it means that if I am doing things
  properly I have to assess the client all over
  again. If I just sign then I feel like I am
  playing games. Then when the report comes to me,
  I end up reviewing it before I realize it should
  go to the NP. (FP)

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Foundational Work to Introduce NPs
• Needs assessment to guide role delineation
• Determination of most appropriate service
  delivery model (collaborative/consultative)
• Creation of supportive environment to promote
  development from novice to expert
• Development of data collection reporting
  mechanisms for accountability quality
  improvement purposes

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners
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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Working Relationships
• Research on patient care teams suggests that
  teams with greater cohesiveness are associated
  with better clinical outcome measures higher
  patient satisfaction. Medical settings in which
  physicians non-physician professionals work
  together as teams can demonstrate improved
  patient outcomes. A number of barriers to team
  formation exist, chiefly related to the
  challenges of human relationships
  personalities (Grumbach Bodenheimer, JAMA 2004)

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Working Relationships
• 85 of MDs practicing with NPs (n 225) 86 of
  MDs not practicing with NPs (n 492) identified
  structure of MD/NP working relationship as a
  facilitator to NP integration
• NPs ranked top facilitator of their role
  integration as personality and philosophy of
  physicians with whom they practice (n253 77
  response rate)
• RNs and other team members

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Role Clarity
• Predictor of integration
• NPs who identified role clearly defined
• Higher job satisfaction
• MD NP satisfied with scope of practice
• MD less concerned about liability issues

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Lack of Awareness re NP role
• Physicians e.g., liability issues
• Public
• Telephone survey of 328 Ontarians
• 45.6 had heard of an NP
• 7.7 had received care from NP in past 12 months
• 67 willing to see an NP for support advice on
  maintaining health wellbeing
• 69 willing to see an NP instead of an MD for
  minor illness such as a cold, sore throat,
  allergies
• (HealthInsider Survey, IBM, 2002)

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• Benefits of NP
• Survey of Patients who Saw NP (n260)
• Spent time answering my questions 86
• Quality of care was excellent 83
• Easy to talk to 79
• Gives support information re health
  problem 76
• Able to see NP quickly 71

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• CNPI Implementation Evaluation Toolkit for NPs
  in Canada
• CNPI Evaluation Steering Committee
• Rob Calnan
• Alba DiCenso (Chair)
• Wendy Goodine
• Brian Hutchison
• Diane Watson
• http//www.cnpi.ca

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Comprehensive Multidisciplinary Primary
Healthcare Integrating Nurse Practitioners

• CNPI Toolkit Modules
• Framework to assess need for NP role
• Steps to support sustainable NP implementation
• E.g., recruitment strategies, supportive
  policies, team building, patient awareness,
  continuing education
• Mechanisms for evaluating the implementation
  process

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