The Northern Adelaide Nurse

Practitioner Project

A Cognitive and Culturally

Sensitive Response to Residential

and Community Aged Care

Judy Deimel NP

Overview • Northern Adelaide Nurse Practitioner Project (NANPP)

• Service providers (1) Helping Hand, (2) ACH Group and (3) Aboriginal Elders and Community Care Services

• Philosophy of respecting culture and cognition

• Nurture, nature and mentoring the nurse practitioner

• Collaboration for successful planning, evaluation & sustainability

– Service archetype

– Key performance indicators

– Barriers and facilitators

– Financial viability

• Conclusion

Background Project Aims

• DoHA funded “Nurse Practitioner Aged Care Models of Practice”

• Improve timeliness and access to care for the most vulnerable and disadvantaged older people i.e.

– Aboriginal and Torres Strait Islanders;

– Individuals with dementia and/or mental health issues;

– Acute illness or acute exacerbation of chronic conditions;

– At risk of hospitalisation;

– Palliative care

• Test the best use of Nurse Practitioner (NP) skills and expertise in aged care

Background Project Aims

• Test sustainable funding models for Nurse Practitioners in aged care

• Identify facilitators

• Overcome barriers to Nurse Practitioners in aged care

• Streamline care delivery for older people when transiting from/to aged care, general practice and acute care

Helping Hand Aged Care

• Residential Aged Care Facility (RACF)

– Ingle Farm 96 places (16 dementia secure), 2 respite, 6+ Transitional Care Packages (TCP)

• Community

– Healthy Ageing Clinic

Commercial Road Salisbury

Coordinators, Allied Health and

NP office

Helping Hand – Gaps and Windows • RACF

– Ingle Farm x 5 General Practitioner meet and greet – GP suggestions = INR, unstable Type 2 Diabetes, Behavioural & Psychological Symptoms of Dementia (BPSD), delirium, antipsychotics, staff education, 1 x “show me your Scope of Practice (ScOP)”

– Ingle Farm weekly intervention meeting

– Orientation week needed to break down the wariness to effect resident review and handover teaching sessions on delirium

• Community

– Consumers with cognitive impairment

no diagnosis; behavioural changes

– Education

ACH Group

• ACH Group already has NPC

• RACF

– Highercombe, Hope Valley 120 places + 15 TCP

– Milpara, Rostrevor 92 places

• Community

– Community East, Newton: Nursing, Care Coordinators, OT, physiotherapist, TCP, DVA, community packages

ACH Group – Gaps and Windows

• RACF

– Emphasis on active ageing ‘Partners in Positive Ageing’ model

– Supportive Residential Services Manager (RSM)

– Transition Care Program – declined NP support

– Early Intervention Working Party 1/12 meeting keen for NP input, source for resident referrals;

– Antipsychotic audit; delirium education

– GP mentor identified; 1 x indemnity discussion

• Community

– Allied Health receptive, TCP RN

Aboriginal Elders Village and Community Care

• Residential

• Aboriginal Elders Village Davoren Park

23 residential places

– Enrolled Nurses and Care Workers (CW) +++, Registered Nurse (RN) 1/7, Activity Coordinator

– 2 GPs, unused examination room (now NP room)

• Community

• Aboriginal Home Care Bowden

– 53+ HACC clients

– Coordinators and CWs +++

Aboriginal Elders – Gaps and Windows

• Residential Identified Gaps

– TRUST and CULTURAL RESPECT

– Systematic resident review (ScOP)

– Education

• Community

– HACC = opportunity for early intervention ,not yet requiring packaged care

– Funding for day respite with potential for NP clinic

– Possible referrals from Muna Paiendi Primary Health Care Service Elizabeth Vale

– Education

Essential Requisites - Cognitive and Cultural Sensitivity

Nurse Practitioner Cognitive Health

Nurse Practitioner Candidate Primary Health Care Gerontology

Aboriginal Elders &

Community Services

Helping Hand Aged

Care

ACH Group

NP Cognitive Health ScOP - Judy Deimel

Declining Memory

Dementia

Delirium

Depression

• Healthy brain ageing

• Comprehensive assessment; Dx/DD

• Living well with dementia PWD/carer

• BPSD - recognisable, understandable, and treatable

• Prevention / diagnostic assessment

• Multi-component non-pharma/pharma management

• Education – person with delirium, staff, family

• Rapport and assessment

• Dx defined by DSM-IV

• Cognitive Impairment, dementia & phenomenology of depression

ScOP Donna Preston

Primary Health Care Gerontology

Person-centred

care Mobility, vigour and self-care

Nutrition

Infections

Dementia

Delirium Depression

Continence

Medication

Skin integrity

Chronic complex

needs

Working Across 3 Organisations Nurturing the NP Schedule

Collaborative Ideal

CONSUMER

NP responsive to urgency

criteria Partnering with host

site #1

Partnering with host

site #2

Partnering with host

site #3

Home, residential

& clinic option

Partnering with GP,

Specialist and Family

Partnering with Acute

Care

Collaborative Reality

• Medical mentoring drawn-out due to project lead change NP initiated resolution

• Geriatrician / Specialist – referral blockers meetings without achieving outcomes 6/12 in NP initiated resolution DBMAS Geriatrician

• GPs letters NPs practice visit informal meeting on site 5/12 later GP Clinic/Round

• Healthy suspicion from some nurses, Care Worker +ve

• Community slow on uptake education sessions

• Forged links with 3 Emergency Departments +ve

Marketing on a Budget

Service Archetype Referral Guidelines

Referral Criteria

1. Client meets NP ScOP

2. Age

3. Catchment Area

4. Treatment (I.E. NP can provide evidence based treatment/ intervention that referrer cannot provide themselves

5. NANPP Referral form completed with sufficient information to enable triage

Service Archetype Referral Form

Referral Pathways

• Helping Hand, ACH Group, & Aboriginal Elders

• Residential / community

• TCP

• GP, SAAS, Geriatric Area Service, nursing, allied health, client, family

Triage

• Nurse Practitioners

• Project Facilitator

• Dedicated email, mobile numbers, fax number

• Meeting ScOP +/- referee notified

• Meeting ScOP client review via:

• Telephone +/or clinic response

NP Assessment

• Consent process

• Comprehensive assessment

• Report sent to referee, GP +/- specialist, family

• Referral to other services (outside NP ScOP)

• Client follow-up short and long term/discharge

• Medi+Assist evaluation

NursePractitioners@helpinghand.org.au

NP Clinical Report

•ISBAR format •Information

•Symptoms

•Background

•Assessment

•Recommendations

Key Performance Indicators (KPI) • Identify best use of NP skill set

– Appropriate, safe, timely and accessible

• Data capture

– – database (location, name, age, sex, ethnicity, first language, referral – reason, date, referee (e.g. Nurse, GP, GP round), date seen, NP name, Medicare, NP referrals, Length of service, date of follow-up, hospital avoidance, referral closed, time for report writing

• Transitioning between RACF, home and acute care

• Identify barriers and facilitators to service delivery

• Education, mentoring, clinical expertise for other HP

• Feedback clinical care/education client, staff and family

KPI Clinical Leadership

• Education: Delirium, Cog Assessment, Dehydration

• Research Projects:

– Audit: Antipsychotic prescribing in dementia audit

– Audit: RACF Dementia diagnosis audit of brain imaging

– Project: Hospital Avoidance

– Project: End of Life Dementia Care (DTSC Palliative Care) and QOL-MB (Quality of Life – Melva Brock)

– Project: NP INR Protocol and Guidelines

• Committees: Aboriginal Elders Dementia Respite

• Publishing: Gentian Violet in Wound Treatment

Northern Adelaide Nurse

Practitioner Satisfaction Survey

Referee & Client Contact Source

Reason for Referral

Location for NP Assessment & Review

6/12 Referral Numbers and Gender

6/12 Evaluation – Age and Ethnicity

Barriers and Facilitators

• Nursing peers

– some suspicion with new NP role

• General Practitioners

– NP recommendations not always welcomed/applied

• Specialist

– reluctant to attend RACF clients

• RACF Health facility – lack of NP role awareness despite letters & orientation – NPs learning the ropes e.g. who what where and why – Insufficient documentation of medical history

• Community - slow on the uptake

Barriers and Facilitators

• NP Project Facilitator Michelle Hogan RN

• NP service information – GP and site letters, brochure

• Setting aside sufficient time for orientation, soft & subtle

• Setting up a referral pathway

• Support from GPs, attending rounds, phone contact

• ScOP and mini version at RACF

• Attending multi-D meetings

• Formal reports in ISBAR format

• Education for staff and clients

• Education resources e.g. delirium, hydration

• Christmas cards; project email updates

Michelle Hogan

The Future - Financial Viability

• Key assumptions - the majority of clients require item numbers 82210 x3 and 82215 x3 reflecting care complexity and patient acuity

• Service sustainability – require average client through put on a daily basis of 6 - 8 MBS clients along with RACF co-payment

• Future

o Secure funds via another project initiative?

o Combined RACF CN wage with MBS remuneration?

Conclusion • NPs working in RACF must have philosophy espousing cultural and

cognitive sensitivity

• Allocate sufficient time for NP orientation to service

• For a successful recipe to develop the NP role - add large scoops of nurturing and mentoring for the person that is the NP

• NPs in aged care address skilled workforce issues where the predominance of RACF workforce are care workers

• NPs improve resident and staff education access

• NPs add value to collaborative case management, care coordination and research findings

• Marketing can be achieved on a low-cost budget

• Collaboration takes time, persistence & persuasion

• Maintain a comprehensive database for KPI and QA

• NP fiscal viability cannot be achieved with MBS remuneration alone

Thank you