Case Study 2: Nurse-led Clinic

karen pippett 200pxWhat motivated you to start a respiratory clinic?

21 years ago we started our first asthma clinic.   Asthma was (and still is) a high priority chronic disease. At the time, the Federal Government provided funds to the Division of General Practice in Adelaide. We applied for and secured funding via a research proposal to set up an asthma clinic in general practice.  We ran the research project for about three years. The practice advertised for a practice nurse and I got the job!  21 years later I am still here!

What services do you provide and how do you identify patients?

Our clinic is Friday afternoons from 3-6pm.  Each patient appointment is 20 minutes, so I see three patients per hour across the three hours. We ask patients to come to see us when they are well. The timing of the clinic allows them to come after work, so they don’t have to take leave.

The first thing patients do is spirometry, pre-bronchodilator.  Then they take their bronchodilator in front of me and I use the opportunity to check their inhaler technique.

Whilst we’re waiting for the bronchodilator to work, we chat so I can document their history. It is amazing what you can learn if you ask the right questions.

If you ask most people how they have been, they invariably answer “I am fine” but if you ask questions like:  ’Are you exercising?’ ‘Have you coughed?’ and ‘Are you waking at night?’ it is possible to quickly determine whether or not they have had more symptoms than they would like to admit or would like to believe.  I ask them what they are doing in terms of adhering to the treatment discussed at the last clinic to establish how effectively they are using their inhaler.

I may also discuss other medication options and prepare my recommendations for the consultation with the doctor.

We then do post spirometry followed by the visit from the doctor to discuss next steps with the patient.

Once the GP is in the clinic, I present the patient’s history. The GP then makes a decision on treatment and when review is required. He will then examines the patient if necessary writes a script.  I then update the patient’s action plan.

The final step is to book the next appointment with the patient and set a reminder.  It works well to make the appointment when the patient is there.

I hope that each patient walks away from the clinic with more knowledge, that they know what to do in an emergency and understand why they are taking their medicines.

How do you involve other members of practice in the clinic?

We have 13-14 GPs in our practice so there are enough referrals of new patients coming to the clinic.  We also encourage reviews for most patients.  I conduct education days with the GPs and the new junior GPs come to my clinics to learn how it runs – this helps with referrals.   Even if the doctors choose not to use the clinic at least they know what I do and how it can benefit them and the patients.

When we first started the clinic 21 years ago we sent letters to all our patients who had asthma and that’s how we recruited patients.  Some patients I have been seeing for 21 years!

Word of mouth is also a powerful tool. People outside the practice talk to people with respiratory challenges and some of them come to our clinic.

What equipment and/or resources do you use in the clinic?

I use an airways model of the lungs to explain the diseases and about breathing. The spirometer is very important!  I used to have brochures for people to take home but now I usually refer them to websites to source information.

What contributes to the success of the clinic?

The dedication and passion of the doctor and nurse is vital.  It needs a good business model so it can be sustainable.   It’s also important to have a nurse who is confident; someone who keeps up to date with the medications and has a passion to learn more.

I would recommend the nurse stay up to date with the latest through continuing education including asthma, COPD and spirometry courses. The GP should also have a special interest and keep up to date with the latest as well, for the benefit of the patients. They should be following the guidelines.

It’s important to have a nurse who has time to dedicate to patient education. Empowering patients with self-management education helps them to manage their disease well.   They learn what their disease is, how the medications work, understand why we ask them to take medications when they are well and why we review their medicines when they are well.  I try to get patients with asthma to understand the benefits of long-term steroid therapy to help preserve their lung function and avoid hospitalisations in the future.

Patient satisfaction is a huge part of the success of the clinic.  If patients feel better and more confident about self-management and have action plans in place they will keep coming back and recommend the clinic to others.

What would you identify as barriers to success?

Funding is a big barrier. We had to change from a research project to a clinic so had to develop a strong business model.  Medicare billing is important. If you bill everything it can be financially viable.

We don’t charge for the clinic. We choose to bulk bill all our patients and always have. I would hate to see patients not coming because they were being charged. It’s difficult to get people to come back when they are well and charge them for the visit.

What else would you like to say to nurses keen on starting a respiratory clinic?

I hope there will be more nurses who want to start respiratory clinics.  Diabetes clinics seem to be popular but respiratory clinics not so.

It could be that Spirometry is the barrier.  It might turn people off.   I think spirometry education is important for nurses.   There is also only a small rebate for spirometry so it’s a lot of work for a small rebate but practice and skill makes it easier and faster and the clinic more efficient.  Of course, then the GP must be able to read and interpret the results.   That can be a barrier too.