Foundations of General Practice : A workbook for nurses
With limited youth-friendly mental and sexual health services available, Bega Valley Medical Practice, located in rural NSW, established a nurse-led Teen Drop-in Clinic, with the main purpose being to increase access to a wide range of health services for young people. Bega’s Teen Clinic has now been operating for three years, and with the local community supporting the initiative, further Teen Clinics are opening in other General practices in the surrounding region.
Bega GP and Practice Principal Duncan MacKinnon was a key driver and supporter of the clinic from its beginnings, with long-held support for the nursing profession and a belief in its potential.
“It always astounds me what patients will divulge to a nurse but leave the GP guessing! The nurse-led model for this purpose, is so fundamentally effective in allowing an easy entry to health care that it is a no brainer!”
See how Teen Clinic applied the building blocks in establishing their clinic
See the patient flow and MBS items used in Teen clinic
A clear plan
Led by Dr Duncan MacKinnon, the Practice Principal, the team at Bega Valley knew they wanted to provide an accessible medical service for the town’s teenagers. Finding information on prevention oriented clinics was difficult, so to support the idea, members of the clinic team visited local schools and obtained letters of support. A formal business plan wasn't created but the team took care to consider the key elements it would have contained: giving the clinic a clearly defined purpose, how it would be funded, how it would deliver care and how it would be marketed.
“We move quickly with changes and give things a try, constantly reviewing on the go."
A business case for a nurse clinic does not have to be an extensive document.
There are no charges for the initial assessment with the nurse in Teen Clinic. MBS items are only billed during any follow up Teen Clinic GP consultations or if a GP Mental Health Plan is initiated. Developing a sustainable nurse clinic model has required a whole of practice approach in supporting the model financially.
Being familiar with Medicare eligibility and claiming rules are critically important when considering how to fund a nurse clinic.
Location and facilities
Teen Clinic operates from a standard consulting room within the Bega Valley Medical Practice and offers a range of general health services, accessible through the clinic's exisitng and available resources: a key reason why the Teen Clinic model works well in a rural town environment.
“Locating the clinic within general practice means the entire practice team is easily accessible and allows the clinic to be more flexible with how appointments are scheduled."
Teen clinics need to be within walking distance from local High Schools.
Staffing and HR
Engaging the team in the setting up and running of Teen Clinic has been a crucial part of the process. While the Principal GP, Duncan MacKinnon, supported the Teen Clinic from the start, gaining the support of the entire GP and practice team during the early stages was all about developing confidence.
"It takes time to engage the whole practice team and may be one of the biggest challenge."
The nurses at Bega Valley Medical Practice have built their knowledge and skills in a number of clinical areas to increase their confidence in working in Teen Clinic. Education has primarily focused on mental health training, reproductive and sexual health. The team also increased their knowledge of local services in the area and referral pathways. Increasing their level of clinical skills and knowledge through further education, has had a positive impact on the GPs' confidence in the nurse-led Teen Clinic.
“You need to show the GPs that they can trust your professional judgement in dealing with these teenagers and knowing when to refer."
Sharing the vision of Teen Clinic with the wider practice team has been important in gaining their support. This has translated into the provision of a more flexible approach to appointments for Teen Clinic patients. For example, appointment times with the practice's psycholgists are now available within a week of being seen at the Teen Clinic, if required.
Using a validated tool as part of the initial assessment assists the nursing team in highlighting areas of risk for teens who access the service. The HEADSS adolescent psychosocial risk assessment covers home environment, education, drugs, sexuality and more. Consent is also a critical issue for adolescents and was raised as a concern by a number of GPs in the clinic. Overcoming this barrier was important in obtaining the support of the GPs for the clinic concept. With the consent of the patient, this process can involve both parents and teachers in supporting them.
"We had to make sure we really understood the law around age of consent and mandatory reporting. We also base a lot of our actions on assessment of Gillick competency, which supports treating anyone 14 and over who is deemed to be a competent minor. If they understand the consequences and the risks of their choices then we are legally allowed to treat them without their parents’ consent. Part of our policy is to have clinicians involved in this process."
Raising awareness of the clinic and its service is an ongoing process. Members of the clinic team visit high-schools, attend community events and speak on local radio programs. A mobile application also helps provide information and advice outside the clinic environment.
Supporting systems and processes
Whilst Teen Clinic operates within the usual systems and processes of the General Practice, the entire practice team has been prepared to adapt and change the clinic model over time, to assist in meeting the needs of those attending. Seeing the GP following a Teen Clinc appointment may happen on the same day if an issue is urgent, or the following day if non-urgent. Patients who require a longer consult will have a double appointment scheduled. Some patients will not need to see the GP at all.
Being flexible with appointment times, and creating opportunities to see patients outside of Teen Clinic times, has been important in increasing access to care for those attending the clinic.
“Over time we’ve become more confident in managing the triaging and making a plan and the GPs have become more confident in what we’re doing as well. So they’re happy for a quick pop-in on the day and then we can save a double appointment for the next day.”
Evaluation and improvement
Increasing access to mental health, sexual health and general health advice in a teen-friendly environment is the key focus for the Teen Clinic team. Having patients attend the clinic is considered the most important measure of success. With no idea of how many patients to expect at the clinic’s commencement, but knowing there were no other similar services in the area, attendance was a key measure in determining the impact the clinic may have in the local population.
During its operation, Teen clinic has seen a gradual rise in acceptance. Teen Clinic receives positive feedback from the community and from teachers at the local high school, who appreciate having Teen clinic as an option for their students. Ongoing data collection, including clinic activity, financial viability and patient satisfaction continue to be monitored and helps the Bega Teen Clinic to constantly evaluate their progress and approach.
“We initially thought numbers through the door would be something that we would measure, which we do, but when we started, we did not have anything to measure it against."
"Young people are still turning up every week with a variety of issues. We see that as a sign of success.”