Aged Care Nurse
Practitioners – developing
models
Associate Professor Christine Stirling,
Chief Investigator
Dr Michael Bentley, Research Fellow
Dr Melinda Minstrell, Postdoctoral Research Fellow Professor Andrew Robinson, Professor of Aged Care
Nursing
Hazel Bucher, Aged Care Nurse Practitioner Lisa Sproule, Nurse Practitioner - Aged Care /
Primary Care Fa culty of Hea lth Science
Background
Ageing population
• Increasing numbers of older people needing services
• Multi-morbidities - complexity
Dementia consistently under-diagnosed
• Around 50-80% of people with dementia undiagnosed
3
Nurse Practitioners
Nurse Practitioners (NPs) = advanced clinical skills
•Masters training with defined scope
•authorised to function autonomously & collaboratively in an advanced and
extended clinical role within defined scope
•role may include, but not limited to, the direct referral of patients to other
health care professionals, prescribing medications and ordering diagnostic
investigations.
•in 2000 NP’s first endorsed in Australia (NSW) now over 600 NP’s in
Australia - (similar roles developed in US in 1960s and UK 1980s)
Nurse Practitioner project
Aged Care Nurse Practitioner development – national project – over 30 sites
– 3 year pilots
IM/NPACT – Southern Tasmanian project
•Nurse-Led Memory Clinic (DHHS)
•NP within Dementia Behaviour Management Service (DHHS)
•ACNP GP practice based
Thank you to Judith Jane Mason & Harold Stannett Williams Memorial
Foundation, administered by ANZ Trustees for their grant supporting the
NLMC research this let to a project grant from the Commonwealth
Department of Health and Ageing. This was an Australian Government
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Our Aims
1.
Trial a nurse-led memory clinic to assess effectiveness and impact
2.
Improve access to primary health, dementia and mental health
services for older persons in general practice, residential aged care
facilities and community.
3.
Demonstrate a sustainable, professionally supported, combination
aged care NP role that can add value to general practice while
Evaluation
Bentley, M and Minstrell, M and Bucher, H* and Morrissey, M* and Robinson, A and Stirling, C, “A case study evaluation protocol to assess processes, effectiveness and impact of a nurse practitioner-led memory clinic”, Health, 6 (8) pp.
748-756. doi:10.4236/health.2014.68096
Mixed methods
• Evaluate memory clinic intervention of 1 NP at 1 day per week over 25 months -• Case Study followed between one - two NPs in a general practice over 2 years Data Collection
Memory Clinic -Demographic and clinical data from clients, videorecording of
consultations, clinic documentation, and interviews with the ACNPs. – description of patients, diagnoses, and interventions – comparison of NP diagnosis to
psychogeriatricians.
GP setting - Descriptive and content analysis of de-identified clinical and demographic details of clients’ episodes of care, Repeated, semi-structured interviews with the NPs.
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The Role Developed
Initial NP Services expected
•
Memory Clinic continued one day per week but commenced
videorecording assessments
•
Two days per week at GP practice, booked own appointments
•Initially reviewed all dementia patients
•
Cognitive assessments in the community setting (2 per day)
•
Comprehensive Medical Assessments on elderly patients in Residential
Memory Clinic Results
Minstrell, ML and Bentley, M and Bucher, H* and Morrisey, M* and Higgs, C and
Robinson, AL and Stirling, CM, “Open referral policy within a nurse-led memory clinic: patient demographics, assessment scores, and diagnostic profiles”, International
Psychogeriatrics: The Official Journal of The Interntional Psychogeriatric Association pp.
1-13. doi:10.1017/S1041610214002361 ISSN 1041-6102 (2014)
• Diagnosis of 106 clients assessed – 45% received diagnosis dementia or MCI • 34% dementia, 13% MCI, 25% depression, 43% no diagnosis
• 60% self-referred of which 30% had either dementia or MCI • 56% of those referred by GP had dementia or MCI
• 100% of allied health professional referral had dementia or MCI
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Memory clinic
Difference to other memory clinics
•
More males than other studies
•
Lower education levels than other studies
•
24% referral were from GPs compared to 59% (+16% other doctors)
•High % of falls (28% versus 15%
•
Clients had > MMSE than those diagnosed in other studies
• MCI 28.2 versus 26.2 • Dementia 24.1 versus 19
•
% dementia, MCI depression diagnosis < others
Limitations
• Small numbers – differences not statistically significant • Limited published information to compare with
GP Clients Seen
:
General Clients Weight Loss Clients All Clients
N = 125 N = 43 N = 168
Median Age 82 (36-99) Median Age 52 (29-79) Median Age 76.5 (29-99)
Male 44% Male 12% Male 36%
Female 56% Female 88% Female 64%
Median Episodes of Care 3 (1-31) Median Episodes of Care 6 (1-12) Median Episodes of Care 4 (1-31) Diagnosis Dementia – 15% MCI – 6% Multimorbidity – 63% Diagnosis Dementia – N/A MCI – N/A Multimorbidity – 10% Diagnosis Dementia – 11% MCI – 4% Multimorbidity – 53%
Multimorbidity – two or more multimorbid conditions as defined by the Cumulative Illness Rating Scale domains (Britt et al. 2008). Ten of these clients were in the weight loss program. Twenty-two (85%) of the clients with dementia/mild cognitive impairment also had multimorbidity .
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Episodes of Care
For internal UTAS use only
Direct Care (all activities performed for and in the presence of the patient/family (Gardner et al. 2010)
•cognitive assessments,
•patient assessment and reviews,
•ordering and/or reviewing tests and medications, and •liaising with family members.
OR
Indirect care (activities performed away from the patient but on a specific patient’s behalf:
•documentation and letters,
• referrals to/coordinating care with other health professionals - including geriatricians, GPs, allied health professionals (e.g., physiotherapists,
dietitians), social services such as home care, and support programs such as programs run by Alzheimer’s Australia.
•
Demonstrating efficacy of dementia diagnosis
•
Gaining support and confidence from GPs and practice nurses
•
Communication e.g. referrals and correspondence with GPs and nursing
staff
•
Determining a sustainable model for the future
•
Access to regular consulting rooms (this access during 2013 meant more
clients were seen in the practice
Currently
–
Memory Clinic continues – other services considering or undertaking
similar nurse led approach
–
1 NP has a contract similar to GPs in practice
–
Access to rooms 2 days per week – name on Practice
–
Provides services to Rural Community Health Centres for Practice (gained
grants for this role).
•
Extended Aged Care scope to include Primary Care
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Conclusion
For internal UTAS use only
There is great potential:
NPs with dementia diagnosis expertise are very useful in
several settings
NPs demonstrated expertise and usefulness to services,
but combined role more sustainable
AND
Still a difficult environment to gain acceptance - Need
an entrepreneurial nurse and practice, with
Contact
For internal UTAS use only
Contact -
Christine.Stirling@utas.edu.au
Papers:
Bentley, M and Minstrell, M and Bucher, H* and Morrissey, M* and Robinson, A and Stirling, C, 2014 “A case study evaluation protocol to assess processes,
effectiveness and impact of a nurse practitioner-led memory clinic”, Health, 6 (8) pp. 748-756.
Minstrell, M, Bentley, M, Bucher H., Morrisey M, Robinson, A, Higgs C., Stirling C. In Print "Open referral policy within a nurse-led memory clinic: patient
demographic, assessment score, and diagnostic profiles”. International
Psychogeriatrics
References:
Britt HC, Harrison CM, Miller GC, Knox SA (2008) Prevalence and patterns of multimorbidity in Australia. Medical Journal of Australia 189, 72-77
Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A (2010) The work of nurse practitioners. Journal of Advanced Nursing 66, 2160-2169.