The nurse practitioner will see you now...

1 July 2012

JILL WILKINSON and ANGELA BATES profile a nurse practitioner-led health centre looking after many of central Wellington’s homeless and high needs population.

Te Aro Health Centre in central Wellington is similar in many respects to other not-for-profit health centres. It has a high-needs population, highly committed and talented staff, and struggles financially – saved only by the grace and generosity of charitable donors.

Where it differs, perhaps, is in the nurse-led philosophy of care. The clinic is led by nurse practitioner (NP)

Angela Bates, who is supported by four experienced registered nurses, one of whom, Wendy Tait, is an NP candidate in mental health.

Te Aro Health Centre is well known for its expertise in mental health and addictions, and over half of the 1500 enrolees experience these types of problems, as well as diabetes, asthma, COPD, skin infections, and other co-morbidities that so often accompany poverty and homelessness. Outreach services, run in close association with the Downtown Community Ministry and the Sisters of Compassion, are also provided for people who are homeless.

The clinic is organised so staff members work at the top of their scope of practice in their speciality area. All patients are seen first by a nurse and then by the most appropriate practitioner, who fully assesses, plans, implements, and evaluates the patient’s care, drawing on the expertise of the team and wider health community as needed. There is a mix of regular planned clinics (for long-term conditions, screening, and immunisation) and triaged queue clinics for patients with acute presentations.

The philosophy of nurse-led care is holistic. Basic nursing education includes training in the assessment of a person’s social context. Often, it’s the context that determines if someone is going to take their medicines or make lifestyle changes, so interventions are tailored to what is known about a person’s life and family.

An example is a man who came to the clinic with leg pain. He had recently moved to Wellington and lives at the night shelter. He has had type-2 diabetes for many years, and although he was taking oral hypoglycaemics, his HbA1C was 110mmol/mol. He said he been prescribed insulin in the past but stopped taking it because nobody gave him the support he needed, he was scared, and he didn’t know what he was doing or if it was working. This time, he was closely monitored and properly supported. He believed if he’d had the right support back then, he could have managed. There is a perception that if people are homeless or deprived in some way that they don’t have the capability to make changes. All they need is the right support – just like anyone else.

A holistic nursing model of care means the staff’s focus is on enabling and supporting people to take charge of their own health. For example, people seeking prescriptions for benzodiazepines are referred to Community Alcohol and Addiction Services (CADS), where they can get help with their problem. Those seeking sickness benefit renewal are properly assessed, and if no longer eligible, will have to shift to an unemployment benefit. Repeat prescriptions for long-term conditions require a medication review, so people are seen regularly and properly monitored. The services people engage with are also reviewed and new referrals are made as their condition changes.

Patients initially resisted this approach because it was new, but their expectations have begun to change. Some have acknowledged that despite their depression, they should work, even if it’s in a voluntary capacity. Others with mental health problems and a supportive management plan in place are phoning – on schedule – to talk to a nurse once a week rather than every day. People understand they cannot reasonably expect to be seen at the clinic if they are drunk (unless acutely unwell), so they now come when they are sober, even scheduling their appointments to suit.

If they are normally mobile, home visits are not offered and they come to the clinic for assessment or medication. People understand they will be charged ($2) if they fail to turn up for an appointment – a strategy that has significantly reduced ‘DNA’s. Importantly, the total number of enrolees has remained the same, despite a highly transient population, and the change in the past year to this model of care.

A team approach is central to a holistic model, and for the last seven months, it has been achieved without a general practitioner (GP) on staff and only one NP after the second NP had to return unexpectedly to the United States in March. A full time GP begins work at the clinic at the end of July, and in the meantime, the centre has contracted locum GPs, who have been supportive and generous with their time.

Staff development is an ongoing priority and all staff members are encouraged to continue with postgraduate study that will advance their practice. The clinic also hosts undergraduate nursing students, medical students, and NP candidates from overseas (Australia and Canada). Case management overview for the NPs is provided by the District Health Board’s GP liaison service, and by the general practice department of the University of Otago’s Wellington School of Medicine.

Responsibility for clinical leadership rests with the remaining nurse practitioner, who experiences the frustration every day of bureaucratic red tape.

After a year of ordering x-rays, she is now told she can’t any more. For patients who need a prescription for GP-only special authority Spiriva, she has to wait until a locum is on site. She can only claim for an ACC assessment as a practice nurse as there is no NP claim category for a NP claim. She can’t claim the GMS (general medical services) subsidy for under-sixes (when there is no co-payment) or for casual patients because the out-dated contract wording stipulates these services must be provided by a GP, even though the same contract states all other first contact services can be provided by a NP. Perhaps the much anticipated Health Practitioner (Statutory References) Bill will tidy up these anomalies.

The capitation funding, services to improve access, very-low-cost access, health promotion, and CarePlus funding streams are barely adequate for such a high-needs population. When the average number of patient presentations a year is eleven (ranging up to 72), the impact of inefficiencies such as those described above are multiplied. Time spent organising ‘work-arounds’ would be better spent attending to real patient need and the important work of keeping people well, out of hospital, and moving forward with their lives.

If those determined to frustrate this model of care were in step with reality, they would realise that nurses with the education, the clinical experience, and prescriptive authority are here to stay … so the nurse practitioner can see you now.

By Jill Wilkinson, senior nursing lecturer at Massey University, and Angela Bates, NP.