PRA NPLC Evaluation

13 MB·English

Research & Contuing
Snes

EVALUATION OF THE SUDBURY DISTRICT
NURSE PRACTITIONER CLINICS

FINAL REPORT

Ootoher 1, 2009

Prepared for:

Ministry of Health and Long-Term Care
Mietryof feats art Long-Term Care
Evatattion ofthe Sudbury District Nurse Practionet Clinie—~October 2, 2008

‘TABLE OF CONTENTS:
EXEC!

TIVE SUMMARY i a 1

LO Antroduction, ss : 6
LL Scope and cbjectives of the evaluation 6
12 Structure of the report, 6

2.0 Program desertion. “7
21 Poliey context _ seen?
22 — Clinic profile msn 8

3.0 Methodology anc . es rs
3.1 Bvatoation questions... wet R
3.2. Document review. one eee
33 Key informant imerviews wos B
34 Focus proups with patients, - atta 18
35 Survey of patients 7 7 13
40 Key findings. wo lS
41 Awareness and understanding, . sn 5
42 Physician integration an en 2d
43. NP-Led Clinic mode! : B
44 Paticnt satistction 7 6
50 ons and lessons learned. ‘ 3L
51 Rationale alii 3
52. Design and delivery ssn nnn 31
53 Satisfaction wus Sov 4
54 Impect senna . 4

APPENDIX A Interview Guides
APPENDIXB Focus Group Guide

APPENDIXC Cover Letter Patient Feedback Survey
APPENDIXD — Questionnaine for Patient

APPENDIXE Reminder postcards Zor Patient Foodback Survey
Evabuston ofthe Sudbury District Nurse Pratidoner Clnies—October 1, 2009

EXECUTIVE SUMMARY

Introduction

This evaluation of the Sudbury District Nurse Practitioner Clinies (SDNPCs) was conducted by
PRA Ine. for Ontario's Ministry of Health and Long-Term Care (MoHLTC). The purpose af the
sty is to identify lessons learned atthe SONPC. whic? will help to inform the roll-sut ofthe
subsequent Nurse Prasitioner-Led Clines in Ontario,

Program Description

In November, 2607. the Ortario government announced thet 25 Nusse Pructitioner-Lad Cliniss
‘woule be established in the province. The establistment of these clinics is intenfed 0 reduce the
snamber of people without primary healt esre providers and sims to improve the
soroprehensiveness und integration of services. Nurse Pracitfonar-L.ed Clinics will be eompesed
‘of a number of healthcare professionals ineluding at @ minimum Nurse Practitioners (NPs) and
piaysicians.

SDNPCs opened in August of 2007 and serve 2¢ a pilot project forthe initiative. The Ministry
Provides funding fr six fl-time NP posits and the cline has two part-time consulting
physicians who see patients and provide formal and informal coasultation so the NPs. Lae
physicians receive a monthly stipend forthe consultions chey provide and are compensated
with feof (FPS) for seeing patients in appointments. Patients ofthe SDNPC are
ass.gred toa specific NP as thelr primary hull eare provider; however, patents are registered
with the clini itself The Ministry expects 4,1) patients to be registered with the elie afer the
clinic’ frst three years of aparation (ie, by August 2010).

Methodology

In consultation wit the Miuisuy, PRA developed a fist of evaluation questions to guide this
sludy (Table 4 in this repos). The questions were cesigmed to align with the guidetines sot out
the RFP. They cover the issues of rationale, dssign ad delivery, stislalion and impact

‘We wed the ‘ollowing lines of evidoree in this evaluation:

= Deeument review
lormant interviews (n = 19 seterviewees)
ent focus groups (n= 20 participants)

= Patient feedback survey (n= 603 respondents)

Fi

ings

‘The findings are presented below in five general themes that emerged from this study: awareness
snd undersandieg. implementation, physician integration, the elie rnodel, aud patient
satisfution
Mieisiryof Heath and Long-Term Care
Evaluation ofthe Sadbuary District Nurse Practitioner Clinies—Octaber b, 2009

Anareness and understanding. ner appears ‘o be « high level of publie awarsness abou: the
‘eustenee ofthe SNPC. tn addition, patients of the clinic apoeas to understand the elinie mode
and the role of an NP. However, the understunding of the model and the NP role is questicnable
‘vith regard tothe gereral publi.

Most participants inthe focus groups care to understand the role of an NP after their First
appointment, when their NP explained their role and the differences herwveen an NP and a
physician. A total of 91% of survey respondents helieve thet they have « clear understanding of
‘he differenoss betwen an NP snd a physician,

ows yroup participants and key informants serceived there bew high level of awareness
ahout the existence of the clic in Sudbury. The ducument review revealed thatthe clinic has

sived a substantia! amount of media attenor, both positive end negative, that has likely
sontribured o the apparent high level of avarensss, The negative media attention was generated
by physicians who questioned the effectiveness, quality af eare received, and ptertial costs of
the elinies, This may have created a lack of confidence in the clinic and initiative, nd an
impression that there is dissention among health eare workers, According to focus aroup
parscipants, tre negative press has caused some individuals o question the cline and more
{generally this model of eare

Implementation, implessentaton issues arising from this stacy were: emcerns with the
[Bleetronie Management Records (EMR) system, élays in receiving budgetary approvals ent
funding, space, and patient complexity. The LMR did not function suioothly forthe Gis: yoar ard
tchulf ofthe clinic's operations fad there was a lack of assistance from the selocted vendor. Th
slinie has siuee noticed improvements and clinic NPs highlighted the benefts of having am EMR,
systema when multiple professionals ure roviding eare so rhe same individual

The cfime received good project management support from of tke Miniscy, However, elinie
‘management said that delays in receiving budgetary spprovals and funding from: the Ministry
have impacted cline operations. In addition, the clinis mazagerrent, Bore members una NPs
sald that a large facility is needed for the clinic. The opening af the next elie in Vey wil
apparent not alleviate this concers. This issue to cave extent, limite the number of patients
that can be registered st the clinic. However, a mate important factar limiting the rumber oF
patients thot can be resistered withthe Riverside elnis has been patient complexity.

New patients of the clinic may not nave eeveived health cane in & number of yeas thasefoee,
patients of the elie can have complex medical useds. Medically complex patieats require mare
‘atention and moze physician involvement, which affects the number of patients that ean be
egistred with the lini, The Ministry expects a patient regisry of 4800 by Aupust, 2010;
however, it is unlikely tht the clinic will meet this target

Physician integration, The custent physician compensation model is not appropriate, and key
informa acnoss all stakeholder groups recommetded inereased physician compensation
Physicians see patients withthe mast complex health needs who roquire longer visits. This bas
‘inanctalimplicaiions because it ransates to sing fevierpatierts pe: day and ewer billable
sits, Adtionally the curves compensation mode! Goes not promote phy sicar. irvelvement in
the clinic,
mtutsty of teats end Long-Term Care 3
Boatution ofthe Sudbury Distiet Nurse Practitioner Clinier—Oetaber 1, 2009

‘A numberof <ey informants said that a sly mode! for physicians of the NP-L ed Clinies could
help overcome the bartiers collaboration as long asthe salury is sufficient, Some key
informants said that having FPS compensation in place at the c:ni isnot ideal because it
remotes diffsrent views of time marayernent wen physicians are the only team members not
‘onsalary. However, the Ministry Rasa fonding agreement with the Ontario Medical Association
(OMA) whereby OMA approval is reguized for any changes to te current funding model

NP-Led Clinie model. The clinic model appesse to work: well, with the excepticn ofthe
aforementioned issue of physician eemnpensation and the zelated isu of limited physician
‘nvolverca inthe clini. The system of patieat registration to the elnic as opposed to enrolment
‘vith an individual health eure provider was percelved as a benefit of the NP-Led Clie model by
patients, clinic sw, clinic management and physicians because it helps ersure continued access
to care for individuals registered withthe clini. In aciltion, the clinic model seems to faciitate
[NPs in functioning to their fll scope of practice, However, thers was a Jeerning curve in terms
of how the toes of different team members sre played in the run of day.

{Key informants were generally satisfied withthe system of iecountability within the cline. Most
key informanss supported having the Clinic Director be an NP. because knowledge of einieal
isoues was seen as essential to management decisions. Fowever, several key informant sed that
the Cline Director in future clinics oes nor necessarily nzed to be an NP, although it would be
necessary to have & senior NP o- physician in charge of the main eliniea decisions

‘The clinic eomplstes reporting forms to track patent encountare and :o ask physician
consulting and sends the cormpletedfors to the Ministry. The wsefuluess of both of these
reporting systems is questionable. NPs and cfinie management sai tha tke ceporting system is
not capturing appropriate results. Ia addition, a number af key informaats across different
stacholdcr yiuups are not wware of how this information is Being used.

Patient sutinfection. Patients showed an overwhelmingly high level of satsfuction withthe
services they recefee from their NP. The main reasons for high sabsfaction were the atitudes of
the NPs and the thoroughness of care provided. When compared with ther previous health ear
situations, patents’ wait times have decreased, In addition, patients are pleased with the hesh
‘education they receive from their NP. Since the elinc opened in Sudbury, tbe clnis's patients
believe that their access to health care has improved.

Conclusions and lessons learned

Conclusions and lessons learned are presented under the evaluation issues of rationale, design
and delivery. sutistietion, and impact.

Rationate. There wer= NPs living in Sudbury who were not employed and who lobbied forthe
lic. which led to its estnlishment. The alinio wes eetablished in Sudbury du tothe shortage
of piysiiuns in the arca ard the esulting high number of patents with no primary health care
provider

Design ard delivery. The current physician compensation model is not appropriate, and was
‘dentitied as the most serious concert in this evaluation. 1T'the made! is noe changed, there wil
de uonsiderable challenges in implenventing the nest 25 NP-Led Clinles because it will be
nase of Heath and Eang-term Care
Evaluation of tae Sudbury Disiice Nurse Practitonet Clinies—October 1, 2009

Aificulewo recruit and retain paysicians, he current madel does not account forthe medical

anplesty of patients being seen and limits physician invnlvement and inpua into the clinic
Physicians ehovld become more involved in the elinie which would he possible with a new
compensation model. I the next 25 NP-Led Clinics are to succeed, negotiations between the
‘Ministry and the OWA are necessary in order te estahlih a envepenestion mode that is attactive
for physicians

With respect to acministativs issues atthe lini: The EMR system was sen ae easel to the
operation ofthe SDNPC, and having an EMR system ig recommended for Future NP clings,
Future NP-Led Clinics should ensure the slcetion of a high-quality LR serviee provides that is
swailable for communication when issues aise. In auition it would be deneficial for all fxure
NP-Ic Clinics to have in place appropiate eles spurt rom the onsct so thet NPs do not
need to take uu clerical duties, This hes impacted operations ‘nilly inthe case of the SDNPC:
Future clinies should also secure failties with appropriate squatc footages trom the onset of
operations, ensuring thatthe ‘scilities they select will mee ther immediate und futire needs
Also, the patient reporting forms and the physician consultation reporting forms noed revisions
0 thatthe information collected is more pertinent. The forms should be re-designed with a goa!
in mind of how the completed forms will be used,

‘The managemert structure with a Clinical Director as an NP appears to work well for the
SDNPC, but may not be nesessaey for all luture NP-Led Clinies, However, forall future clinics,
‘here should be a regulated heal professional in charge ofall clinical operations :o ensure shat
Someone with appropriate penis i involved in clinical decisions mae, Iz ndditon, for fare
clinics, logistics of the way in which elinic team members play thie roles should be discussed ot
‘the oasct of clinic operations,

NPS atthe eine are fimetioning to their full scope of practice. The nature of the clue mee!
Facilitates this because NPs ace primary eal‘ eare providers ac therefore deal witha bread
‘ange of health issues. The collaborative relationship among NFs and herwean the NPs and
‘hysicians is another factor facilitating NPS in functioning to their full scope, Future NP-Led
‘Chines eould ensure that individuals hired to work at the clinics have the ability to work ina
‘eam setting. Moreover, physicians could be provided with training about the role of NPs atthe
elinie,

There isan apparent need to increase pcblic understanding about the role of an NP and the NP-
‘Led Clinies initiative in general. Tae negative media atsntion received in Sudbury may aecer in
ctber areas where NP.I ad Clinios are eing implemented. A provineial media campeign led by
the Minisny was recommended to ineceese public undcrstanding about she initiative. The
‘campaign could focus on educating the publie about how health services are delivered in this
lyre af'modol, including the roles of NPs end physicians atch clinics

The clini isnot likely to reseh the target ef 4,800 patients by August 2010 while nintaining the
quality of sevievs its currently providing. The medical complesity uf yates at the eine fs
affecting the number uf patients chat ean be registered, The Miaisty can lagk to the capacity of
the SDNPC when planning for future clinis 1 estate the ruber of pstients chat can be

Q
Minty of Heal and Long-Term Care 5
Evaluation of the Sadbury District Nurse Pracitiouer Clinies—October b 2009

‘Satisfaction. Pationts ate genstelly highly satistied with the serviees they receive from the elinie
and with the cri itsel®. They appreciate the postive and rospoctul attude of their NP, end ate
comfortable asking questions. Patents also appreciated having access to plysicians when
needed, and are satslied with the thorough care they reveive, They appreciate the amt of tire
‘that is spent with thera per visit and the good listening eels of their NP.

‘The NPs, doctors, and cther stakeholders who wore interviewed generally showed a high lvel of
satisfaction with the clinic. NPs appreciate heing able ro Rencton to thei fll scope eficiently
and in an empowering seting,

Impact. Patients registered a tho einie perceive major differences inthe primary health care
they roecive since the elinie was opened, especially given thal prior tothe sini, they hed no
primary health care provider. By providing primary health ewe access ro indviials who
previously had none, the elinie pears to be un eflecive vay to improve access to primary
Islth eave in Sudbury

More gencrally, the next 25 clini can Jeam ftom the experiences of the SDNPC by

communicating with the SDNPC abot implementation challenges that *hey have faved, The

Ministry could provide support Zor the SDNPC to shave information shout ost practices and

lessons lesmed with other clinics. In addition, the Ministry would need to snsure enough stalling
the provincial level to assist with the rollout of the next 25 eines,
Minisiry of Heat and Long-Term Care 6
oaiuaton of the Sudbury District Nurse Pratitoner Clines—October 1, 2009

1.9 Introduction

‘This document constitutes the Final report for the Evaluation of tae Sudbury District Nurse
Practitioner Ciinies (SDNPCs). his evaluation was conducted by PRA Ine. for Ontario's
Ministry of Health and Long-Term Care (MolILTC, also refered to throughout this repor! as
“the Ministry”).

44 Scope and objectives of the evaluation

‘The purpove of this evaluation isto identify lessons learned at the SDNPC, which will help to
inform the roll-out of the subsequent Nurse Pructitoner-Led Clinies in Onvario, The main
evaluation issues we examined were rationale, design and delivery, satisfaction, ard inspect,
Evaluation questions ander each ofthese issues were developed and can be found in‘Table4 on
rage 11

As per the Request for Proposals (RFP). the evaluation examined the following arcas:

> Rarrers and facilitators tothe implementation of the SDNPC, including stakcholdees
perspectives and lessons leumod,

> Pationtielient access to comprehensive pusary health eure services:

> Pacieavelieat sat'sfietions and

> Invegraton and collaboration bewween Nurse Practitioners (NP), emily
‘other providers.

siclans and

1.2. Structure of the report

“Te reports divided into several sections, Sesion 2 includes the poliey eoatext relating tothe
clinie’s implementation and presents a profile ofthe clinic. Section 3 describes the methodology
used to complete the evalustion. In Soction 4, the findings from al data collection activites,
carried outa part ofthe research are presented. Sectfon 5 concludes this report, and discusses
‘the lessons leamed as they relate to the implementation af the next 25 NP-L clinics im Ontarie
Muntstry of Heath end Long-Term Care 7
Evataaton of he Sudbury District Nurse Practitoner Ctntes—Octobor 1, 2009

2.0 Program description

‘This section discusses the policy context m which the SDNPC's were implemented, followed by a
protic of te clnie.

24 Policy context

[NPs are Registered Nurses who have “extended elas” designations with the College of Nurses
of Ontario, They have an expanded scope of practice in the areas of health assessiment, diagrosis,
ordering tests, preseribing treatments and heylth promotion. When patient care needs extend
beyond the scope of an NP. they enmsult with a physician in aecordanee with guidstines
established by the College of Names of Ontorin (2009)

NPs have come to be ognized as playing a key rls in the healh cave system, In Ontario, the
MolIL-TC has funded a mnmher of initiatives since 1998 dedieated to resting and sustaining NP
positions in Ontario, with a focus on underserviced areas (e.g, Nurse Practitioner Demonstration
project and funding to increase 2linical sducstion postions), The MolILTC contin to fand
initiatives volving NPs, most recently withthe large-scale NP-Led Clinics iitatve

In November of 2007, the provincial government announced chat 25 NP-Led Clinies would be
«slubiished in Onterio. The establishmert ofthese elincs is intended t@ reduce the number of
‘people without primary healt care providers and increase access to healt: cate. The elnies are
‘also intended to imprave the comprehensiveress and integration of services. The implementation
of these clinies is part of the Ontario Government's Family Care or Al Siceuy, which aims
provide comprehensive, avessible and timely health eare for Ontarians (Caoyernment of Ontato,
2000",

The clinics emphasize chronic disease management and health prometion. This is deme throwgh
treatment end monitoring, as well es thugh improving the sills of patents to manage ther
‘own health (Governmert of Ontario, 2000¥. NPI ad Clinics will be composed of a number of
health care professionals, including at a minimum NPs and physicians. However, having ¢ renge
‘of healthcare professionals in NP clini is possible, with providers working celaboraively as 2
health eare delivery team. The Rommnows report (2002)"detcmnined that this type of inter-
professional care isa direction for the farnc of healdh ware iu Canad

‘The Ministry funds a similar initiaive — the Pantily Health Team (
Led Clinies, FHTs aim to provide collaborative health care for
ealth care provider. A total of 150 FHTTs have been created since 205, and napther 50 will he
‘implemented. A key difference between FHTs and NP-Led clinies is that wih NP-Led clinics, an
NP acts asthe primany provider of health care and serves & point of entry ta the health care
‘stem. NPs consult with physicians as apprepriate. In the FHT model, pafsieans are the
Svimery health care providers, Both the FITS snd the NP-Led Clinics ae being implemented
tnd planned in regions acres the provines

17) initiative. Like the NP-
viduals who da not have @

Selection of sites. Tae Miaistry undertook a nevds assessment considering nvange of
population and health indieatnrs to determine which Local Health Integration Netwocks (LENS)
‘have the greatest need for edditional resources, These LHINe ars: North Wi
Mintsery of Heath end Long-term Care 8
Evaluation of te Sudbury District Nurse Practoner Clinies—October b 2009

Si, Cait, North Simeoe Muskoka, Central West, Central East, Champlain, and South East. Key
Indicators for assessmg need inched:

~ Proportion of unactached patients, excluding the Heslth Care Connect pm
Prevalence of one or more of nine cheonic diseises, inclnding diabetes

= Number of fulltime equivalent (FTE) general practitioner / family physicians isthe
LHIN per 16,000 popetation: and

- Number of existing FETs / Community Health Conte

To dete there have been two calls for applicaons (waves) forthe NP clinies. Three NP-Lec
Clinies were announced in February 2009 as pare of Wave I It is expected that suscesstial
applicants for Wave 2 will be annoueed in te fll of 2009.

‘The SDNPC; the subject ofthis evaluation, was
plat project for the invtntve, snd is discussed in

rst established. Ti
following section

22 Clinic profile
This section provides a aroile of the SDNPC by discussing the rationate forthe pe: project in
Sutbury lending to the establishment ofthe clinic. This is followed by & description of the
finie's main activities, mamagement and organization, and resources.

2.2.4. Rationale and clinic establishment

Announced in November, 2006, The SDNPC was intended as a three-year demonstration project.
‘The projec: was established in Sudbury, Oatario, for several reasons,

Although Sucbury isthe largest city in northeen Qatari, tis considered underserviced when it
‘comes to health care. On some of the key determinants cFheslth, Sudbury scares lower than the
ses of the province (eg. education, incor, health (Statist Canada, 2006). Prot to ‘he
sstablistment of te clinic, there were a number of NPs in the Sudhury azea who wers imable to
Sind employment and were avaiable for work. Some were considers moving from Sudbury fe
other regions nf Ontn-o or to the United Seates for employiment

A group ofthese NPs ecllaborated and lobed for a NP Led Clinic. They were not sucecssful in
‘heir application under the FHT Initiative; however, the Ministry appoved ths clinic separately
in Novershor af 2006, This vas one yser prior to the anacuncement cf the lage initiative, Funds
rom the Ministry hegan to low'in May of 2007. The elinie opened its doors in August of 2007
and began gistering patients immediately. A timelice ofthe events leading to the establishment
of the SDNPC is presented below in Table 1

"Table 1: Tintin of events leading te Sine esuibishment

Event T Month, year
SDNECarcunest— —Tioverber 20085
‘SONG roooived funding fam Minh Hay. 2007. =}
'SDNDG arenes August, 20077
[ NBLles Cinics inate ennauneed — Revenber, 2007 |