The University of Canberra is finalising an evaluation of Australia’s national project to expand the role of nurse practitioners (NPs) in aged care, which is due to be handed to government next month.
In the absence of Australian research, the national evaluation of the three-year Commonwealth-funded NP in aged care program will provide much-needed evidence of the effectiveness, financial viability and sustainability of NP models.
Around Australia some 32 projects have been funded under the $18.7 million program, which involves a range of models utilising NPs.
Despite the role being in place in the US for nearly 50 years, NPs are a relatively new addition to aged care in Australia and in 2012 made up only 0.2 per cent of the residential aged care workforce. Even smaller numbers were found in the community care workforce, according to the most recent national aged care workforce census and survey.
The national evaluation will provide a unique opportunity to compare models of practice and pave the way for the development of this advanced practice role in aged care.
One aged care provider that was successful in securing funding under the government’s program was Brightwater in Western Australia.
The residential and home care provider used the grant to hire two full-time NPs, Lorraine Martin and Leah Hansen, who were employed to work across eight residential aged care facilities, north and south of the Swan River, as well as across some home services.
Martin and Hansen say their addition to the Brightwater team has improved the timeliness of medical care and contributed to a reduction in antipsychotics and inappropriate antibiotics use among the resident population.
From left: Brightwater NPs Lorraine Martin and Leah Hansen
While NPs have prescribing rights like GPs, Martin says an important part of their role is also to review and de-prescribe unnecessary medications. “In the frail elderly there is lots of evidence that polypharmacy is very harmful, so at every consult we review the medications to make sure they are appropriate,” she says.
Inappropriate transfers to hospital emergency departments have also fallen since the availability of NP consultations. “There have been many instances where the staff would have sent someone to hospital but our involvement has meant that we have been able to make a diagnosis and manage the person on site.”
Martin says their inclusion at Brightwater has also helped fill a gap in access to medical care, particularly in former ‘low care’ or ‘ageing in place’ facilities where GP access is poor.
Model of care
While the Brightwater NP model was originally developed to focus on chronic disease management, Hansen says the model rapidly evolved from a specialist to a generalist model to address the multiple and complex needs of residents.
From vaccinations to continence management and end of life care, Brightwater’s NPs are involved in a large spectrum of areas of clinical need.
Hansen says her consultations take a holistic approach and involve not only managing the presenting condition but also looking more broadly at the persons’ overall health to diagnose and treat early.
Martin describes their role as delivering proactive healthcare. “It’s very much about the prevention of complications before they arise rather than reactive healthcare and dealing with an issue when it happens,” she says.
“We are looking at the person as a whole, so we would look at everything from pain relief, their continence, sleeping, diet, immunisations and all their chronic health conditions. We review lots of different things that can’t be done in a five or 10 minute consult.”
Martin says as a supernumerary member of the nursing staff she doesn’t feel the same pull from the floor to be doing lots of other tasks.
“It takes a lot of time to fully understand the history of the client’s medical conditions, their social history, and the family dynamics, so having the time to be able to do that means that we can get a really good insight into that person and be able to support the staff in managing them.”
Providing professional support and clinical leadership to carers and nursing staff is also a key element of their work and an important way of ensuring best practice is followed by facility staff, says Hansen.
GP workload
Since the introduction of the NPs, the workload of visiting GPs has decreased substantially and facilities have reduced their reliance on locum GPs, with benefits to continuity of care for clients. “A GP who worked with us said he would never work in an aged care facility again without the support of a nurse practitioner because he had been overwhelmed by the demand from the site,” says Martin.
Challenges
Martin says due to the recent development of the NP role in Australia, public and professional awareness and understanding of the role has presented an early challenge and while most GPs have been open to the involvement of a NP, others have expressed a resistance to collaboration.
Financial reimbursement of the role through Medicare rebates is also a significant issue. Increasing the access to, and the value of MBS item numbers for NPs, will be critical to improving the financial viability and long-term sustainability of nurse practitioners, says Martin and Hansen.
Despite these financial challenges, Brightwater has agreed to continue to employ the two NP positions following the completion of the Commonwealth-funded project in June 2014.
Collaborative care
Working interprofessionally and in close collaboration with their GP colleagues is an important aspect of their work, says Hansen.
“Although we can do a lot of what a GP can do, our roles are quite different. We think quite differently but putting us together delivers improved outcomes and quality of life for residents.”
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