APNA's definition of primary health care nursing covers health, scope of practice, primary health care, roles and settings. We also explore general practice nursing and Phillips et al. six roles of the general practice nurse.
SKIP into LIFE
SKIP into Life is a person-centered clinic which aims to improve the health and wellbeing of people with enduring mental illness by preventing and managing chronic disease. It is part of the Worrigee Medical Centre, a bulk billing practice near Nowra, South Coast NSW, with a SWPE of 5030.
“A typical patient is somebody that has a mental illness that tends to be unstable still or sub-optimally managed with diabetes or heart disease or respiratory illnesses and they're in desperate need of help.”
Christine Turpin, the Practice Manager, said she saw the clinic as providing a great benefit to patients, with more time to connect with them and gain a better patient outcome.
“I personally believe nurse clinics would be an asset to any general practice for the patients.”
See how the SKIP into Life clinic applied the building blocks in establishing their clinic
See the patient flow and MBS items used in the Skip into Life clinic
A clear plan
Clinical nurse consultant Ros Rolleston and Practice Principal Dr Annette Pham have been the key drivers for this clinic which began when the Worrigee Medical Centre credentialled mental health nurses expressed a need for help in managing their patients’ physical illnesses. Including Chris Turpin and Office Manager Hayley Dolphin in the planning averted potential administration issues. Goals included shared decision making and continuity of care as well as early referral to specialist services. A literature review was carried out first, with an examination of the clinic’s data to assess patient need.
“I did a literature review before the proposal so that I could see what the needs were, not just assume what they were. That was really, really important. If you don't actually look at the evidence then you're not going to be doing the best job.”
A budget was developed for the project, but without the skills or experience to do this, help was sought from Greg Davis, CEO and the HR manager. The clinic is funded solely by the Medicare Benefit Scheme. The GP is always a part of the SKIP consultation and this collaboration is central to the funding model
“I just set it all out and thought to myself, ‘Where will we spend the money?’”
Location and facilities
The clinic runs one day a week, with its own dedicated consulting room.
“There's been a couple of times where we have considered moving, but it's not worked out because the GPs often come into my consult and see the patients. I need to be central for that to occur.”
Staffing and HR
One of the biggest challenges has been implementing change in a large organisation and achieving consensus. Administration staff have not been allocated, which has affected the clinic’s ability to keep up with paperwork including financial modelling. More time spent in the planning stages may have averted later problems with allocating administrative resources.
“Roles and responsibilities need to be nutted out with everybody that's involved over a series of meetings. It needs be written down into the clinic model and agreed to.”
External service providers, including dietitians, physiotherapists and optometrists were brought on board by the simple method of identifying providers and ringing them up to introduce and explain the clinic.
“I go to workshops, mental health professional webinars, still looking, still constantly looking at the research, particularly around the medications because they've got such disastrous cardiometabolic effects.”
The McCormack and McCance model of person-centered care is used for the clinic, emphasising holistic care and engagement. Reflecting the multidimensional nature of this clinic, other resources used are a cardiometabolic screening tool; the NSW Mental Health Clinical Documentation Guidelines, the DSM-5 and various diabetes, cardiovascular and respiratory guidelines. The PDSA quality improvement approach was helpful in clarifying the goals of the clinic, but there is some disappointment that the quality improvement needs highlighted have not been implemented.
A new care plan template was designed by the clinic, but also implemented by the wider organisation. Active listening skills were found to be the most important, because people with mental illness often need a lot of encouragement to share information.
“People with mental illness often need to download a fair bit before you can get to the nitty gritty. If you don't spend the time with them, you'll never get there.”
Supporting systems and processes
While the clinic has a reminder system, it has been frustrated by lack of resources. Data colection has also been affected by this shortfall in the project. This has been challenging and enlightening with valuable learning about our processes
Evaluation and improvement
Baseline and ongoing health data have shown improvements in patients, specifically in the areas of HbA1c, BMI and blood pressures. Concurrence with medication regime has improved, as has communication with GPs, who are handling less paperwork during SKIP consultations so have more time to talk with patients, strengthening therapeutic relationships. People with mental illnesses require a lot of encouragement to be a part of decision making. Signs of success are also when people articulate their needs and opinions.
“The big one is that the patients come back … and as time goes on they come prepared with questions.”
“I would say that it's a resource intense process, particularly in setting it up and then the first three to six months. But the potential learning for the whole team and the improvement in the quality of care is just absolutely worth it. You see a person who's been agitated, frustrated and angry now smiling and laughing and it's worth it.”