Academic journal article Australian Health Review

Practice Nurse Involvement in General Practice Clinical Care: Policy and Funding Issues Need Resolution

Academic journal article Australian Health Review

Practice Nurse Involvement in General Practice Clinical Care: Policy and Funding Issues Need Resolution

Article excerpt

Introduction

In Australia, as in many developed countries, the demand for primary healthcare services is steadily increasing, mainly due to an aging population, growing burden of chronic conditions such as diabetes and shifting care from hospitals to primary care.1 Strategies to develop a more sustainable health workforce within this setting, while improving the quality of care, are urgently needed.

Over the past decade, the Australian Government has imple- mented several initiatives, including the Practice Nurse Incentive Program (PNIP) and nurse-specific Medicare Benefits Schedule (MBS) items, to encourage general practices to employ practice nurses. This is consistent with the Australian National Primary Health Care Strategy, with an emphasis on prevention, self- management and team-based care, all with significant implica- tions for nursing roles.2 The recent growth in the primary care nursing workforce has been largely driven by these policy initiatives. The national practice nurse survey estimated there were 10 700 practice nurses in 2012, compared with 7725 in 2007, with 63% of general practices now employing one or more practice nurses.3 It is expected that the number of practice nurses working in general practice will increase further in the coming years.4

Several systematic reviews and clinical trials have found that collaborative care with the active involvement of nurses in clinical management processes is effective for the management of chronic conditions in primary care.5-9 In their review, New- house et al.10 found that patient outcomes with collaborative care are similar to or better than care provided by physicians alone for a range of chronic conditions. A meta-analysis of 34 randomised controlled trials found that practice nurse involve- ment in clinical-based activities is associated with improved glycaemic control in patients with diabetes.6 Studies also found that nurses provide effective care for the management of obesity in primary care.11,12 Although international evidence has shown that clinical-based task delegation to nurses for the management of chronic conditions is cost-effective,11,13 there is as yet limited evidence on the combined impact of the Australian practice nurse workforce on patient clinical outcomes and healthcare resources.14,15 Such locally relevant evidence is required to underpin informed and effective policy and planning decisions, which may lead to the expansion or redirection of scant financial incentives.

To address the above issue we designed the Primary Care Services Improvement Project (PCSIP).16 The PCSIP was a 3-year observational study (October 2007-October 2010) and used routinely collected data. The aim of the PCSIP was to estimate costs and outcomes associated with two levels of practice nurse involvement (high vs low level) in clinical-based activities (e.g. patient education, self-management advice) in the management of chronic conditions, such as type 2 diabetes and obesity. High- or low-level practice nurse involvement in clinical-based activities was identified via a survey of practice nurses employed at participating practices. Level of involvement was informed by responses to questions about the percentage of diabetic (or obese) patients seen by a practice nurse in the participating practice, and the percentage of time spent on clinical-based activities in a consultation with a diabetic (or obese) patient. A high level of practice nurse involvement was defined if the average response of the practice nurses within a practice was >50% on both these questions, and the practice was assigned to the high level of model of care. Practices with practice nurses that did not meet these criteria were assigned to the low-level model. Details of PCSIP-diabetes and PCSIP- obesity studies have been published elsewhere.17-19 A summary of their methods and key findings is given in Table 1.

The findings of the PCSIP provide significant evidence that more intensive involvement of practice nurses in clinical-based activities for patients with type 2 diabetes and obesity is cost- effective and can significantly improve patient outcomes (e. …

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