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Care Plus Workshop |
Summary Practice Nurses Experience of Providing Care Plus and Care for Lifelong ConditionsResults of the Workshop Held for Primary Health Care Nurses27 October 2006 – Palmerston North Sponsored by College of Nurses Aotearoa (NZ) Inc. and College of Practice Nurses – NZNO
Prepared by: Michal Boyd, RN, NP, ND
Introduction A national workshop was held on October 27, 2006 in Palmerston North to provide a forum for primary health care nurses to discuss their experiences with providing chronic illness care. Although the Care Plus programme was the focus of the workshop, discussion about all programmes for chronic conditions was included. This workshop was jointly sponsored by the College of Nurses Aotearoa (NZ) and the College of Practice Nurses division of the New Zealand Nurses Organisation (NZNO). The workshop was attended by 88 nurses who came from all over New Zealand and represented practice nursing, chronic disease specialists, nursing leaders, researchers and educators. It was facilitated by Joanna Harper from Harper/Devine Consulting.
The purpose of the day was as follows:
The day included presentations about various aspects of chronic illness care delivery. From the Ministry of Health, Saskia Patton presented an overview of the Care Plus evaluation data and Richard Mclachlan d iscussed Care Plus within an outcomes framework. Jayne Hill presented her experiences as a Care Plus coordinator for Manaia PHO in Whangarei. The group also heard from Christine Nicholas from Piki Te Ora Maori Nursing Services in Taranaki. Michal Boyd's presentation provided information about key knowledge requirements for nurses providing primary health chronic illness care. Julia Ebbett, Care Plus Coordinator from Hawkes Bay PHO, presented information about tools and IT innovations for chronic illness care. These presentations provided a basis for participant feedback sessions held during the day. The following is a summary of the themes from the participants' feedback regarding their experiences with chronic illness care.
Positive Benefits of Nurses Providing Care Plus and Chronic Conditions Care
Increased opportunity for Client Centred Care: Nurses involved in well developed Care Plus programmes discussed how these encourage a client centred approach to chronic illness care. When properly implemented, they promote individualised goal setting and personal empowerment. The funding of chronic illness programmes such as Care Plus increases access to health care by providing extra free visits and provides the time necessary to assess self management knowledge and ability. This care encourages goal setting that is based on the person's priorities, rather than the health care provider's priorities. It is clear that successful Care Plus programmes actively promote the self management skills that are crucial for improving the health of people with chronic conditions. Improved Health Outcomes: Nurses were extremely enthusiastic about the improved patient outcomes that resulted from greater client self management. Many nurses recounted success stories about people they partnered with for Care Plus. They were clear that chronic illness effects every aspect of a person's life, therefore a holistic approach is required that goes beyond the medical aspects of the disease. Care Plus funding allows for greater flexibility in how care is delivered. Many nurses commented that when they had the time to counsel people with chronic conditions, they were surprised by the power of incorporating a person's unique circumstances into care. They found it greatly improved the effectiveness of the intervention. It was reported that the data from patient surveys indicated that Care Plus influenced overall quality of life for those actively engaged in the programme. When fully developed and with adequate time and support, Care Plus and other chronic illness programmes had a positive impact on the health of those with chronic conditions. Appropriate Use of Nursing Expertise: The nurses reported that they experienced greater job satisfaction through improved patient outcomes and felt their expertise was valued Care Plus created an opportunity for team building within the practice and increased collaboration with GP colleagues. Care Plus was considered a way to raise the capability of the practice nurse workforce. This type of care increases the practice nurses' care coordination role for people with complex circumstances. In this coordination role, the nurse provided information about community resources and appropriate referral processes. The participants noted that the care of people with chronic conditions is an excellent role for practice nurses. It also promotes the use of clinical pathways and protocols for people with lifelong conditions.
Barriers to Providing Care Plus and Self Management for People with Chronic Conditions Lack of Nationally Consistent Tools and Resources : There are currently no nationally consistent resources, such as assessment and goal setting tools, care protocols, patient education resources and coordinated information systems. The lack of information sharing has meant that every PHO has expended considerable time and resources to reinvent Care Plus from the ground up. It was perceived that there was a lack of nursing in-put into chronic illness care policy and funding developments at a local and national level. There was a call for some mechanism by which PHO's could share their tools and resources nationally. Nurses would also like better developed guidelines for new Care Plus providers and more uniform resources, developed with greater nursing in-put. No Consistent Outcome Measures: The lack of consistent outcome measures has made it impossible to compare the health gains of Care Plus nationally. The dearth of analysis and dissemination of outcome data was perceived as a barrier to implementing best practices for chronic illness care. Currently, the only required outcome data for Care Plus programmes are the number of people enrolled. This has created a disincentive for primary care practices to use Care Plus funding as a self management counselling and goal setting tool. It was reported that many practices have used this funding as a “tick box” exercise to get enrolees quickly, rather than as an innovative mechanism to increase the time available to promote self management skills. There was a call for the Ministry of Health to provide patient outcome requirements that go beyond enrolment numbers. Benchmarking of clinical indicators was seen as important to improve Care Plus delivery and provide needed outcomes. Nursing Workforce Development: Recruitment and retention of nurses in primary health care is an issue. This issue has become more serious since the MECA agreement for DHB nurses. New graduate programmes for primary health care nurses have been developed in some areas, and many would like to see this expanded to encourage more graduate nurses to become primary health care providers. There is poor workforce development for nurses providing chronic illness care. Many nurses do not have the time or financial resources to attend formal post graduate study. This is partly due to the small business model in primary health care and the lack of education funding available. The inability to cover their positions while they are away from their practice for education is also an issue. Very few practice nurses have had specific education in chronic illness care, self management skills, motivational interviewing and effective goal setting concepts. Nurses expressed the need for national funding of chronic disease management training for practice nurses. It is important that this education be in module form and provided via distance learning mechanisms such as on-line learning and by DVD . Logistical Barriers to Delivering Self Management Programmes: Implementing Care Plus was often done in addition to current responsibilities, and therefore many practice nurses were reluctant to take it on. The participants reported that there were many rumours which suggested Care Plus increases the workload for an already overloaded nursing workforce. This created a disincentive to implement the programme. Practice nurses providing counselling about self management need dedicated, uninterrupted time with the person, as well a private space, which was not always incorporated into the implementation of Care Plus. GP Perceptions of Patient Ownership: Nurses felt that in some cases, the GP perceived they “owned” their patients and their medical records, and were reluctant to share information with other providers. Issues arise regarding sharing of patient medical information across health care settings and with other team members involved in the person's care. This is particularly true for health care providers working with patients in NGO's and in secondary care services. The inaccessibility of medical records across primary and secondary care resulted in coordination gaps and duplication of patient information gathering and testing. Some GP's saw Care Plus as a solely nursing intervention, and therefore did not consider the patient self management plan as an integral part of medical intervention. Participants expressed the importance of the collegial relationship between practice nurses and GP's to ensure the best outcomes for Care Plus. For example, it was very important that the GP became an active partner in careplan development with the person and the nurse. If the GP does not value the self management plan it impacts on the person's motivation to be actively engaged in self management programmes. Invisibility of the Nursing Contribution: The general practice small business model was seen as a barrier to full nursing autonomy and effective practice nurse interventions. .Many participants discussed the lack of acknowledgement of the financial contribution they had made to the primary health care practice. The participants felt that alternative funding models that recognise the financial contribution of nursing are needed. This contribution should be reflected in the practice nurse salary which is not currently the case. In some areas nurses have contracted with PHO's to provide Care Plus services. In this model, the medical records and the Care Plus funding continued to be held by the GP, who is invoiced by the Care Plus nurse for her services. Chronic Illness Care Funding Silos: There is little coordination between chronic illness programmes. This creates confusion and competing programme requirements. Currently there are several funded programmes for chronic illness care in primary health which include Diabetes Get Checked, Care Plus, Falls Programmes, Green Prescription and many others. All these programmes have separate funding schemes, and for people with several co-morbidities, there is an overlap in programme requirements that has created a documentation burden. It was suggested that Care Plus become the umbrella programme under which funding for all chronic care programmes would sit. There was consensus that the administrative processes for Care Plus and other chronic disease programmes needed to be streamlined and simplified. Variability Care Plus Programme Eligibility Across PHOs: There is wide variation in the individual PHO eligibility requirements for Care Plus programmes across PHO's. For example, some PHO's limited their definition of a chronic condition to a chronic disease such as diabetes, or congestive heard failure. Other PHO's considered chronic conditions to include health problems such as obesity and/or cigarette smoking. It was also unclear where chronic mental illnesses fit into the definitions. This was particularly difficult because of the distinct funding silos for mental health care and primary health care. Broadening of the definitions of chronic conditions increased Care Plus enrolment. For some practices serving individuals with high needs, the number of people in the practice that are eligible for Care Plus often exceeded the 5% funding cap. This problem was addressed differently by the PHO's. For instance, one PHO may state that Care Plus funds can only be used for 5% of patient's in each practice, whereas other PHOs will interpret this requirement as 5% of all their enrolees across all practices. Some practices enrolled well below 5% of their patients in Care Plus while other practices enrolled well above the 5%, but this would average out to 5% of patients across the PHO. . Suggestions for Enhancing the Delivery of Care for Lifelong Conditions Community Resources Knowledge and Access: A directory of community resources is needed for nurses delivering chronic illness care. This will facilitate better Integration with other local community agencies and resources, particularly NGO's and secondary services. In order to do this, nurses require improved access to local resources. For instance, better access to dietician and podiatry services was extremely important for many people. Other resources needed include exercise and fall prevention programmes. Participants discussed that for high needs clients, very little health promotion can happen if they have other issues such as housing, employment, financial or mental health issues. Better access to other resources such as transportation, housing and WINZ was also seen as necessary. There was a desire for improved access to social workers, counselling and social services.
Flexible Programme Delivery Requirements: Some nurses expressed the need to evaluate the frequency of visits required for an effective self management programme. For instance, it is very difficult for clients to stay motivated for behaviour changes such as smoking cessation and weight loss if they are only seeing their health provider partner on a quarterly basis. More intensive contact is often needed at the beginning of a self management process in order to provide the support required for true behaviour change. Some PHO's have used SIA funding to provide weekly visits for patients who need this extra support. Other nurses suggested a mobile Care Plus programme, delivered via outreach, could be of benefit for people who are difficult to engage. There was also a suggestion that the different needs of rural vs urban clients should be evaluated. Coordinated Education Needs: A coordinated approach to education is needed, including different education delivery methods (modularised education and internet based education that can be delivered by distance learning). The development of centres of excellence was also discussed. These could act as core training centres. Multi-disciplinary team approach: It was suggested that a multi-disciplinary team be developed that included experts in specific areas of chronic illness care. This was envisaged to be at the PHO level. For instance, a cardiac nurse specialist, respiratory nurse specialist and a gerontology nurse specialist, along with a dietician, pharmacist, physiotherapist and social worker could be available for consultation, promotion of the guidelines and to increase evidence-base practice. These professionals could also be available for joint visits with the practice nurse when support and guidance were required. This could also be a way to incorporate secondary care specialist expertise into the primary care setting. Local and National Nursing Leadership for Chronic Conditions Care in Primary Health Care: The nurses perceived that there is currently little nursing representation on national primary health care working parties. They expressed a need for improved nursing representation on political and Ministry of Health groups. There was a consensus that a national nursing steering group for Care Plus and chronic condition care is required. Outcome Measures and Continued Development of Care Models: The participants felt it was important that primary care models promoting self management of long term conditions continue to be developed. It is important for these models to promote the integration of nursing and the multi-disciplinary team across all health care settings, including primary, secondary and NGO providers. The extension of lifelong conditions programmes beyond PHOs and contracted providers is required for a more responsive delivery model. A national approach to outcomes measurement that goes beyond enrolment numbers is required. These outcomes must include patient clinical outcomes, but also information about which aspects of the delivery methods are working and why they are working. Many participants discussed the need for a national mechanism for shared learning about models, tools and resources. Increased Media Coverage for Self Management Programmes: Participants noted that there has been very little coverage in the national media about the availability of self management programmes. This is in contrast to the extensive media coverage for the menNZb campaign. It was suggested that successful Care Plus programmes be spotlighted in the media to encourage people in the community to seek them out.
Summary of Elements to increase the Success of Care Plus Programmes
Steps Agreed Upon following Workshop: The Care Plus workshop provided a national voice for primary health nurses to suggest changes in practice as the emphasis continues to shift to new models of self management and chronic conditions care. At the end of the day, it was decided that the College of Nurses Aotearoa (NZ) Primary Health Care Network and NZNO Primary Health Care Council will work together to develop a strategic plan for chronic illness care by primary health care nurses. The first meeting has been set to occur in collaboration with the Ministry of Health after the new year. This summary of the findings will be published in Te Puawai through the College of Nursing Aotearoa (NZ), NZNO's Kai Tiaki, Nursing Review and GP publications. This report will also be provided as feedback to the Ministry of Health for future Care Plus and chronic illness care developments. A strong nursing voice is crucial for the continued development of the profession in promoting self management and care of people with long term conditions. The ultimate goal is to empower nurses working in primary health care so that they may improve the overall quality of life of people with chronic illness.
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