Case Study 1: Nurse-led Clinic
Judi Wicking has been working as a nurse since 1975 and running nurse-led respiratory clinics in general practice since 2001. You could say she was pioneer in this space! Judi shares her invaluable knowledge about how to set up and run a clinic successfully.
“I often tell patients that we want them in the clinic when they are well, to keep them well and to prevent them getting sick. Education is difficult when patients are not feeling well.
The asthma and respiratory clinic provides an opportunity to give a whole consultation to a patient on one particular aspect of their health.
During the clinic I talk to them about chronic disease management as a journey. I explain that we have to work together over a 6-12 month period to ensure we are doing the absolute best for their health.
The asthma and respiratory clinic is not a one stop quick fix. It’s a process, as with any chronic disease, which takes time…”
What motivated you to start a respiratory clinic in your general practice?
In 2001 I was approached by the Whitehorse Division of General Practice to participate in a pilot project on the delivery of a nurse-led asthma clinic in general practice. The Division knew of my general practice experience and interest in asthma, at the time I was working as a research nurse and studying in this field. While learning to be a research nurse I was fortunate to have information and education provided to me by my supervisor which changed my life. As someone with asthma I had never had a lung function test or comprehensive education, just scripts with a little bit of information and so my quality of life and use of medications was not ideal. I was so thrilled to be asked to start up the clinics as I had personally experienced the benefit that time spent and education can make.
What does the clinic look like?
Soon after the clinic commenced it was broadened to include COPD and the clinic was retitled, ‘Asthma and Respiratory Clinic’ as there is so much overlap of these two conditions.
I deliver a couple of different clinics – a full day and 2 half day clinics in different practices across a fortnight. I spend 60 minutes with new patients and 30 minutes for a review. Patients appreciate having significant time allocated to discuss all aspects of their respiratory health and their new found self-management skills. It only takes 3 patients to get a clinic started and from then on 1-2 new patients per clinic as the reviews fill the other appointments For fortnightly clinics approximately 35 new patients per year are required.
What kind of services do you provide in the clinic?
The clinics are suitable for any person with asthma, COPD, those requiring spirometry or assistance in smoking cessation.
The service delivered depends on whether the patient is a new patient or is a patient that has come in for a review. For new patients we would:
• Take a full history
• Conduct a relevant health assessment including a risk assessment
• Perform spirometry
• Provide self-management support including smoking cessation, inhaler device technique, written action plans , and general healthy lifestyle education
• Assess their immunisation status for influenza and pneumococcal
• Referral to other services/health professionals such as:
o pulmonary rehabilitation
o support groups
o National Asthma Council and Lung Foundation for patient resources
o Allied Health Professionals e.g. Pharmacists for a Home Medicines Review
• Prepare a General Practice Management Plan (GPMP) if appropriate
• Provide guidance on where to access resources such as inhaler device videos and downloadable literature
On the review appointment the progress of the patient is discussed, medication usage assessed and device use checked, self-management support provided, tests conducted as needed and referrals made if required.
How do you involve other members of the general practice in the clinic?
Having a team approach to patient care really makes a difference. It is essential to involve the GP, particularly relating to the diagnosis and medical management e.g. medicine prescription/changes.
For each patient, their own GP or a GP from the practice is included in the consultation. It becomes a three-way conversation with the patient, doctor and nurse talking to each other and clarifying questions. This helps with consistency of information and ensures everyone is on the same page.
The nurse-doctor professional relationship is very important. The patient gets the best of both worlds with two health professionals with different skills sets and different scopes of practice working together for their benefit.
The reception staff is invaluable with promoting the clinic, appointment scheduling and confirming appointments prior to the clinic to reduce the number of no shows.
What equipment and/or resources did you access prior to commencing the clinic?
Upskilling training is important and I would recommend that nurses starting a clinic consider undertaking:
• A spirometry training course
• Asthma Educators course
• COPD training online and face-to-face
• Smoking Cessation
• Allergy updates
An up to date spirometer in good working order is essential and these can be free standing or linked to computer software. The consumables to conduct spirometry will need to be accessed for this activity.
Resources such as placebo inhaler devices, wall charts, airways models, videos and printed materials are useful in helping to providing education to patients.
Systems need to be put in place for recalls and reminders as well as the collection of data. Each patient is given a visit slip to ensure they go back to reception to make follow-up appointments and finish off their Medicare claim for bulk billing. These slips can also be used for the collection of data. It is important to provide feedback to the practice on the outcomes of the clinic.
It is critical for the nurse educator to be very aware of what is evidence-based best practice; know how to access current guidelines for asthma and COPD and understand their implementation. Find ways to keep up to date and upskill their knowledge. Register for mailing lists and become a member of organisations like LFA, NAC, Asthma Foundation and TSANZ. Find a mentor/peer if possible. Increasing knowledge on all things respiratory increases confidence and the potential to promote the clinic model of care to doctors and the practice.
How did you recruit patients to attend the respiratory clinic?
Initially we use a few different methods to recruit patients to the clinic, these include:
1. Direct referral from doctors – This is most effective because patients take notice of doctors’ recommendations
2. Sending letters to pre-identified patients in the database – Most practices will have enough patients to fill the clinics. The best way to find potential or suitable patients is to search the patient database for those who have been at the practice over the last 12 months and have been prescribed inhaled medications. Additionally search for smokers and ex-smokers.
3. Team care nurse/practice nurse can also identify patients who have respiratory concerns
Once the clinics are well established referrals seem to be ongoing with regular new patients and the support of the GPs and practice staff.
What do you identify as critical success factors in delivering the clinic?
It’s not easy. Find a champion within the practice who is passionate about the respiratory clinic being a success and recognises that the practice and patients will benefit from the service. The champion might be a GP, the practice nurse or the practice manager who can help to convert the GPs. It is absolutely essential to have at least one or two people 100% behind this this model of care otherwise it won’t succeed.
Build a strong professional relationship with your doctors so that they refer to you. The exchange of information between patient, nurse and doctor is also very important and can only be achieved if the professional relationship between doctor and nurse is strong.
Be aware of team care arrangements ensuring the respiratory clinic is included as part of the team.
Be sure to identify potential risk factors that could affect the success of the clinic e.g. lack of referrals, lack of practice support, changes in MBS item numbers.
Any final words of advice?
It is no good trialling for only 3-6 months, you really need to run the clinic for at least 12 months. You won’t see the benefits of the item numbers until after 12 months and this data is required to illustrate the financial viability and sustainability of the clinic.
Hang in there. There will be ups and downs and the specialist nurse will need to be committed to face and resolved any presenting challenges. The rewards are definitely both personally and professionally satisfying.