Horowhenua NP making a difference in rest homes September 2013

The first NP employed by the residential aged care sector led to far fewer hospital admissions and reduced GP workloads, says an evaluation report. But in a sector always plagued by funding issues, the report also raises questions over the sustainability of the current funding model. FIONA CASSIE reports.

The ‘before’ and ‘after’ statistics at three Horowhenua aged care facilities clearly show nurse practitioner care can make a difference, according to an evaluation report.

Elderly residents’ visits to the emergency department fell by 28 per cent and acute hospital admissions fell by 22 per cent after NP Sylvia Meijer began working with the three facilities.

Over the same 12-month period, the ED visits and hospital admissions at three similar facilities, used as comparisons, both rose on average by 21 per cent.

The evaluation report, funded by Health Workforce New Zealand (HWNZ) and led by Dr Kathy Peri of the University of Auckland, aimed to evaluate the impact of the country’s first NP appointment to residential aged care facilities.

It concludes that it is a successful collaborative initiative and recommends that “serious consideration” be given to implementing a model of care enabling more NPs and GPs “to work in partnership in caring for older people in aged residential care facilities”.

“It’s all falling into place very nicely,” is how Meijer, (profiled in Nursing Review December 2011) describes her NP role which she began in early 2011.

She is employed 0.6 of the time by the Masonic Villages Trust and Enliven Presbyterian Support Central to work across three facilities in Horowhenua and the remaining 0.4 of the time by the Central Primary Health Organisation (PHO) to lead the local Health of Older Persons (HoP) team.

Meijer’s role links primary and secondary services for the elderly, allowing her to network and draw on the knowledge of geriatricians, GPs, nurses, and other clinicians working in the field and refer clients quickly when needed.

“It’s very collaborative and that’s really what’s made the role for me.”

She is also involved as an NP and team leader in strategic work and clinical projects in falls and dementia.

“It’s a really very promising and satisfying job,” says Meijer.

Meijer has also been pleasantly “surprised” by the impact her role has made on ED presentations and hospital admissions.

She puts part of it down to her daily facility visits and ability to set up preventative care plans as well as respond to any acute issues on the day that fall within her scope.

“So that means when the GP goes into the facility, some of the things that the GP would usually do might already have been done, or if I’m there when the GP visits, we might discuss the best way of going forward for that patient.”

Meijer’s regular visits also allows nurses in the facilities to recognise and act quicker to put in preventative action to stop issues exacerbating rather than holding off until the GP’s next visit. She also provides the quarterly reviews for residents, which would previously have been carried out by a GP.

The evaluation report included focus groups and interviews with facility staff and managers. Nursing staff and care managers reported that improved continuity of care was a major advantage, with Meijer being able to provide timely diagnosis, prescribing, and care plan direction for resident issues, particularly with UTIs, skin infections, and wound care. Other benefits raised included the education role that Meijer played, more collaborative and patient-centred care plans, and a reduction in anxiety for nursing staff and caregivers knowing they could call on Meijer for help.

Three GPs working for two of the facilities were interviewed and noted they would not have been as attracted to supporting aged care facilities without the NP to share the workload. They said it was crucial for the NP to be skilled and competent which meant they could trust her to do much of the routine work and liaise with them over residents with complex needs.

The report also notes that while the NP is likely to be reducing costs to the health system ¬– through reduced hospital admissions and reduced drug prescribing – these savings aren’t flowing to the facilities employing the NPs.

Both general managers of the facilities shared concerns around the sustainability of the current joint funding model. One believed the shared funding arrangement was a workable model for an area that did not easily attract GPs. The other was looking for cost savings to offset the cost of the nurse practitioner and remained concerned at the continued GP and ambulance costs.

“The aged care facilities have indicated that funding the NP role is not sustainable long term unless the direct cost benefits can be evidenced,” says the report. Both organisations also say the current aged care-funding model created an “impediment to change” and made adding a new resource to improve care quality “very difficult”.

“We’re trying to do things differently, but we’re still using old-fashioned funding models,” is Meijer’s response to the issues raised. “I think that’s where the challenges are.”

The report recommends that the current funding model for the NP be reviewed, including looking at financial modeling and measuring the savings to the health system.