julie fereday, central institute of technology and kylie mayo, roaming education and community...

reach Roaming Education and Community Health

. WA International Training Provider of the Year 2013

REACH is a community health initiative that provides:

• • •

Health services to partner organisations Mobile health check services Nurse practitioner services

•  Students invaluable practical experience in the management of acute and chronic diseases

•  Maximises support and care for clients that tend not to engage with established health services

•  Over 800 students have completed 5 days clinical placement

•  An innovative new clinical training service that has reduced demand on already overburdened health services

•  Created engagement between students and the primary health care sector offering students invaluable experience outside of what has been traditionally on offer

•  Greater exposure to a diverse range of community settings

•  Thousands of community health checks

WA International Training Provider of the Year 2013

Population Health Checks (PHC)

Student Nurses provide health checks to groups within the community. These services are delivered at Independent Living Centre’s, Shopping Centres and Community Centres: REACH PHC works with clients and organisations to: •  Undertake preventative health checks •  Provide health education to promote and achieve good health •  Build on confidence and competence level of student nurses •  Support organisations to provide health checks and support to employees/members

Student Self Evaluation of Clinical Skills Day 1 and Day 5


Population Health Checks (PHC)

The students started completing the population health checks in September 2012 and have since completed over 5,766 checks on members of the community in a variety of settings.

Of the participants, the students have recorded details for 2151 males and 3615 females

•  1913 are aged between 16 – 30 and 800 over the age of 70

•  1194 referrals have been made

•  346 encouraged to return to future health clinics for follow up

•  778 verbally recommended to attend GP, participant provided with written record of results from health check

•  333 had health education material provided to them

•  1 participant was immediately referred to emergency


Nurse Practitioner (NP) Health and Wellness Services

The nurse practitioner provides expert primary health care across a range of community settings. NP works in partnership with other reach staff to optimise primary health care service delivery that encompasses marginalised groups including:

• • •

Socially disadvantaged Migrant and refugee groups Homeless youth

Major focus of service delivery is to provide accessible and equitable health care to clients while providing NP students, EN and RN students with: • • • •

Comprehensive primary health care experiences Client assessment and management Skills in health education and promotion Experience in development of chronic disease management plans

NP implements best practice, improves quality and leads research into primary health care.


Reach Wellness Centre (RWC)

Delivered on-site to participants from one of Central’s partner agencies, typically the residents selected do not access primary health care services and are often not attached to a general practitioner:

• • • • • •

Build relationships with participants Monitor and provide support to achieve health related goals Move towards achieving good health, providing support to reengage with health services Work collaboratively with other health professionals referring participants as required Assist them to navigate the health care system Nursing students play a key role in undertaking initial health assessments, listening to the clients and providing vital health education services.

Students Self Reflections

‘I finally learnt that you cannot let prior personal information, like drug or alcohol abuse, affect the way you treat someone’ Student Nurse

‘The varying placements offer students a variety of challenges including overcoming the language barrier, socio- economic variations, a multitude of ages, nationalities and various stages of life. I believe that I have learnt more in two days of placements than I have in four weeks of text book learning.’ Student Nurse


REACH Wellness Centre (RWC)

The services provided by REACH have filled a critical gap identified by St Barts, James Watson and Wandana Flats in supporting the health care of their residents. Residents involvement has been the key to the success, with many taking the opportunity to have an initial conversation about their health in a setting where they feel secure and supported. Since July 2013 when REACH first commenced there have been 658 one sessions with data including: The services provided were:

•  121 Initial Health Checks •  170 Self presentation with health concerns •  372 Follow ups and monitoring of health •  53 One –on One Health Education •  55 Wellness Sessions •  25 Referrals from Members of the Residential Facility

239 Referrals have been made: •  122 to the REACH Wellness Centre for follow up for further monitoring and health education •  41 Verbal recommendation to attend GP, participant provided with written record of results from health education •  44 Written communication/letter to GP or NP outlining further details of why referral indicated given to participant •  18 Phone contact with GP or NP outlining immediate health concerns •  14 Immediate referrals to emergency


Lifestyle Assessments- Independent Living Centre's

A relatively new arm to the REACH program, there have been weekly visits to the Independent Living Centres with Student Nurses attending to between 10-15 residents each time.

When this program commenced it was with the intention that the students would provide a referral pathway to the local GPs and resources for health concerns for the residents. However as the program has progressed, we have found that the majority of the participants actually had a very good awareness of the available to them and good ongoing relationships with GPs.

The benefit to the participants is more of a social interaction with the nursing students and their feeling of satisfaction in assisting in the training of the next generation of nurses. We have found that participants that previously displayed signs of anxiety and interaction and contact with the students is being embraced positively by the residents.

Students Self Reflections “Today I completed an assessment of activities of daily living on a gentleman from Parry House. He was extremely willing to openly discuss his life and his battle with depression. He gave me a great insight of what it is like to live with a mental illness and how he copes. He made me feel welcomed and commended our student nurses on doing such a great job. I feel extremely privileged to have been given the opportunity to interview this gentleman and feel I gained much from this experience.”

“The interview today was a great experience. I was able to be in a person’s home environment and see how they live independently within this community. I feel the client was relaxed and open with me which made asking questions and talking to the client easy on both ends. She enjoyed having someone new to talk to about both health and personal life.”


REACH Nurse Practitioner Clinic

Principles •  Social inclusion •  Equity •  Priority for vulnerable individuals and communities •  Collaboration with other providers •  Students play a key role in service delivery •  Building a body of knowledge


REACH Nurse Practitioner Scope of Services

2 key focus areas:

•  diagnosis, treatment, and referral services for patients seen in REACH clinical service areas

•  supervision of nursing and nurse practitioner students


Competencies required

•  Competence to diagnose and treat across the age spectrum •  Competence to diagnose and treat acute and chronic health conditions •  Proficiency in billing fee for service •  Proficiency in current standards of practice •  Proficiency in measures of quality of care •  Proficiency in ICPC-2 Coding •  Proficiency in teaching students •  Cultural sensitivity


REACH Nurse Practitioner Clinic Initial Set up

Key Issues 1. Current pool of NPs not trained, experienced and confident in the breadth

required to operate effectively in primary care environment

2. MBS items do not reflect the broad range of services that NPs provide, neither are they adequate to provide a living wage without subsidisation


Medicare Items Comparison Table: GPs and NPs GP Code

Item Location MBS rate NP Code

Item MBS rate BB

NP % of GP rate

3 Straight forward Consulting rooms $16.30 82200 Straightforward $8.00 49% 4 as above Not consulting rooms or RACF $41.30 Nil 19% 20 as above R esidential A ged C are F acility $61.25* Nil 13% 23 Less than 20 min Consulting rooms $35.60 82205 < 20/60 $17.50 49% 24 as above Not consulting rooms or RACF $60.60 Nil 29% 35 as above RACF $80.55* Nil 22% 36 At least 20 min Consulting rooms $69.00 82210 At least 20/60 $33.15 48% 37 as above Not consulting rooms or RACF $94.00 Nil 35% 43 as above RACF $113.95* Nil 29% 44 At least 40 min Consulting rooms $101.55 82215 At least 40/60 $48.85 48% 47 as above Not consulting rooms or RACF $126.55 Nil 39% 51 as above RACF $146.50* Nil 33% 2100 Telehealth 5/60 Consulting rooms (outer metro) $21.60 Nil N/A 2125 as above RACF $65.65* Nil N/A 2126 Telehealth < 20/60 Consulting rooms (outer metro) $47.10 82220 <20/60 $23.60 50% 2138 as above RACF $91.15* 82223 <20/60 RACF $23.60 26% 2143 Telehealth >20/60 Consulting rooms (outer metro) $91.35 82221 >20/60 $44.80 49% 2179 as above RACF $135.40* 82224 >20/60 RACF $44.80 33% 2195 Telehealth >40/60 Consulting rooms (outer metro) $134.40 82222 >40/60 $65.90 49%

as above RACF $178.45 82225 >40/60 RACF $65.90 37% Note 1 : only similar, time - based items have been compared. NPs do not have access to Medicare EPC or procedure items such as Health Assessments (#703 standard = $132.70), Team meeting for CDM (#723 = $109.95, RMMR (# 903 = $101.95), reco rding ECG (#11700 = $30.65) etc. Note 2: On average, patient attendance at Consulting Room to see NP attracts 49% of GP rebate, community visits (home visits) RACF visits = 25% of GP rate. Telehealth consults in rooms also 49%, and at RACF average 33% of GP rate. * A complicated formula is applied if up to 6 patients or more than 7 patients are seen (reduces total amount of claim) attendance at RACF . The Digure shown here if for one patient seen in RACF.

MBS Analysis

March 2013- Nov 2013 OOS 585 MBS Eligible 441 Age range 18-‐ 97 First contact 16% Follow up 84%

Consultation type MBS Rebate No. Consults Revenue Brief consultaBon (82200) $8.00 44 $352.80 Standard consultaBon (82205) $17.50 88 $1,543.50 Extended ConsultaBon (82210) $33.15 221 $7,309.58 Long ConsultaBon $48.85 88 $4,308.57 Total MBS Revenue 441 $13,514.45


The Opportunity

•  The volume of potential patients for NPs through this model is significant •  The opportunity to combine an educational model within the NP clinic with

a business development model to promote the role of the NP in WA should not be underestimated

•  Needed to find a model that provided a living wage for the NPs but also provided a strong incentive to build their own practice

•  The potential for health policy, health administration and clinical practice research is currently untapped.


The Plan

•  Establish an Academic Nursing Centre operated by Curtin School of Nursing and Midwifery- REACH APAC

•  Utilise faculty NPs and clinical tutors to support NP novice practitioners to extend their skills in primary care

•  Leverage existing referral sources through Central’s to “case find” and refer •  Establish and implement an electronic medical record for use throughout all

REACH sites •  Share patient level data (DE identified) for research purposes •  Create an internationally recognised centre for Primary Care Research directed by

Curtin that will focus in areas such as quality, safety, and effectiveness of care


The Model


Research Items for REACH

Demographics of Patient served:

1.  Numbers 2.  Ages 3.  Sex 4.  Ethnicity 5.  Primary language spoken 6.  Currently identify a GP

Reason for Visit – Should be recorded using ICPC-2

1.  Screening 2.  Wellness follow-up 3.  NP visit for Dx & Rx

a.  Diagnosis (all) Again, use ICPC-2 for this b.  Prescription provided c.  Referral made - & to whom WA International Training

Provider of the Year 2013

NP Visits Evaluation

Need to develop some measure of NP treatment against some established standard for each type of treatment

Financial/cost evaluation

1.  Calculate cost/visit (personnel, overhead) 2.  Generated reimbursement for service delivered 3.  Potential reimbursement for service if full GP rate allowed 4.  Potential reimbursement for service if all codes allowed at BP rate 5.  Other income streams – teaching, research


Service Development for NPs

•  Partnership with Central- Small business management •  Partnership with Frontier (US)- DNP Primary Care •  Hard financial targets

•  Year 1- 20% MBS 80% clinical supervision •  Year 2- 30% MBS 60% clinical supervision 10% research grants •  Year 5- 50% MBS 10% clinical supervision 40% research grants


Work still to be done

1.  Create the evidence base- particularly economic benefit 2.  Advance the role of NPs in primary care 3.  Push the policy agenda- NPs must be able to earn a living wage outside of

the hospital sector 4.  MBS is a one size fits all- NPs are not a homogenous group- the funding

strategy should reflect this


So can an NP practice be financially sustainable?

•  Not if you only use MBS as a revenue source •  Not if you don’t want to charge patient co-payment •  Not if you want to practice in a truly holistic way that takes time and

reflects the differences between medical practice and nursing practice


Julie Fereday Learning PorRolio Manager -‐ Health Central InsBtute of Technology [email protected]

Kylie Mayo Director Service Development Reach [email protected]


julie fereday, central institute of technology and kylie mayo, roaming education and community...

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