Comparing and contrasting 3 models of Nurse Practitioner MRP in Ontario public hospitals PANEL DISCUSSION SEPTEMBER 22, 2017 Hôpital Montfort, Ottawa Vanessa Helleur NP (Adult), BScN, MN St-Joseph s Health Centre, Toronto Sharon Mulsant BA, BSN, MSN, NP - Adult Lakeridge Health, Whitby Dr. Michelle Acorn DNP, NP-PHC/Adult PRESENTATION OBJECTIVES To explore 3 different models that have the Nurse Practitioner (NP) acting as the MRP (Most Responsible Provider) for admitted inpatients. To discuss successes and challenges to ongoing practice as well as strategies to work around existing barriers. To explore opportunities to expand these models into various departments of public hospitals as part of a shifting paradigm for care delivery. 1
PRACTICE LANDSCAPE To our knowledge 3 hospitals in Ontario have successfully operationalized Nurse Practitioners (NPs) as Most Responsible Providers (MRPs): Lakeridge Health in Whitby Montfort Hospital in Ottawa St-Joseph s Health Center in Toronto This model reflects recent regulatory and legislative changes to the Public Hospitals Act (Reg 965, 1990) which enable NPs to admit, treat and discharge patients admitted to Ontario Public Hospitals HÔPITAL MONTFORT Francophone academic hospital affiliated with the University of Ottawa Provides bilingual services as part of a hospital system serving 1.2 million people Received accreditation with exemplary standing from Accreditation Canada Designated Best Practice Spotlight Organization (BPSO) by the RNAO One of the 30 best employers in the national capital region 2015 & 2017 Over 1800 employees, 289 acute care beds and 11 operating rooms Over 7 500 surgical interventions, 3 800 day procedures per year and 57 000 emergency room visits per year OTTAWA, ONTARIO 2
MONTFORT MODEL Nurse practitioner providing onsite coverage 08:00-16:00 Monday to Friday. Patient rounding, team meetings, family meetings After hours, holiday coverage and emergency after hours coverage provided by hospitalist team Patients are generally stable, frail elderly who do not qualify for rehabilitation programs and are at risk of needing LTC. NP AS MRP PRE-IMPLEMENTATION 4CM Frailty Unit 21 patients 4CM Frailty Unit 21 patients 10-11 patients admitted to Dr. X 10-11 patients admitted to various hospitalists on a rotating basis 10-11 patients admitted to Dr. X 10-11 patients admitted to Nurse Practitioner MONTFORT MODEL Montfort Date of implementation July 2016 Number of attending NPs, case load Number of admissions & discharges Patient selection and profile 1 Adult NP, 5-10 beds 32 Admissions, 28 Discharges, 0 deaths 7% of discharges to LTC (93% to other destination) Patients selected at the discretion of the NP. Ideally stable, frail elderly patients at risk of requiring long term care Frequency of rounding Afterhours coverage, planned and un-planned absences Approach to legislative and regulatory gaps Mondays + Fridays + PRN, NP available on unit during regular business hours for RN/families Hospitalist team provides coverage Medical directives authorized by the Medical Acts Committee. Consult with physician collaborator for assistance. 3
MONTFORT MODEL Mentorship and support for NP Access to emergency medical consultation in decompensating patient General reception by colleagues,patients and families Montfort Dedicated physician collaborator to provide mentorship and guidance RACE team available in hospital and access to full complement of medical specialists on a consultative basis CritiCall from patients requiring off-site service Patients and families very pleased with service, no patient/family has refused care by NP Colleagues for collegial and supportive although coverage remains an ongoing challenge Biggest ongoing challenge After hours coverage Access to CritiCall is tenuous Biggest success Navigating the challenges of implementing this model ST-JOSEPH S ACatholic community teaching hospital affiliated with the University of Toronto. We are a vital resource providing specialized paediatric services, family medicine and dedicated programs for senior populations. Our teams also manage several chronic illnesses at our ambulatory clinics including mental health, cardiology, diabetes and nephrology. Every year we see more than 100,000 visits to our ED, 20,000 inpatient admissions, 180,000 diagnostic imaging tests,200,000 visits to our clinics Each year our teams perform over 25,000 surgeries, deliver more than 3,000 babies, see more than 2,500 visits to help children with their mental health We provide hands-on learning opportunities for1,300 medical residents and interprofessional students. Toronto, Ontario 4
ST-JOSEPH S MODEL NP assumes MRP for 30 beds on the 45 bed unit, available M-F 8:30 am- 4:30 pm. Also provides care on other acute medicine units Rounding weekly and PRN, Weekly interdisciplinary team meetings for discharge planning Conduct family meetings, admissions and discharges including dictations and prescriptions NP on call every other week on all 45 beds shared with MD Pre Nurse Practitioner MRP 45 bed unit One MD to cover all patients, admissions and discharges. No vacation coverage Same MD on call 24/7 Post Nurse Practitioner MRP NP covers 30 beds, MD covers 15 Shared vacation coverage, Shared call, Reduction in after hours call Less provider burnout Better patient care Enhanced nursing skills in assessment and patient management ST-JOSEPH S St-Joseph s Health Centre Toronto Date of implementation September 2015 Number of attending NPs, case load Number of admissions & discharges Patient selection and profile Frequency of rounding Afterhours coverage, planned and un-plannedabsences Approach to legislative and regulatory gaps 1-Adult 1-back up for call schedule (recently retired) 45 bed unit NP has 30 beds. Avg 5 d/c week Beds counted as acute. Pts are ALC. NP can treat any acute medical illness without transfer if within (her) scope of practice. Exclusion Criteria: Isolation, telemetry, ventilation, Suctioning frequency greater than q4h, peritoneal dialysis, CADD/PCA pumps, involuntary psych admission Weekly notes/visits NP Present daily for family/rn concerns NP splits call with MD evenings and weekends. Also cover for each other with absences Diagnostic imaging tests ordered under MD name. Wanderguard ordered under MD. Formed patients through psychiatry 5
ST-JOSEPH S Mentorship and support for NP Access to emergency medical consultation in decompensating patient General reception by colleagues,patients and families Biggest ongoing challenge Biggest success St-Joseph s Health Centre Toronto MD collaborator. NP can consult any MD if necessary Part of acute hospital. NP to evaluate if present on unit. REACT team available if patient meets criteria. Transfer to GMU or ICU if NP deems necessary. ER doc available for overnight issues Very positive. Families, staff, interdisciplinary teams, MD colleagues very supportive Medical directives (who signs off?) NP MRP model implemented with success, better patient care with 2 providers and not just one, call system put in place with staff education, RN/RPN buy in for nurse as MRP LAKERIDGE HEALTH Whitby - Post acute specialty hospital 5 sites: Bowmanville, Oshawa, Whitby, Ajax & Port Perry One of 30 best employers Durham region NP as MRP only at Whitby site NP in/outpatient roles: o Oshawa (GAIN, mental health - eating disorders/addictions, dialysis) o Whitby complex diabetes o Ajax - medicine Whitby, Ontario 6
LAKERIDGE HEALTH MODEL Free standing specialty hospital, No emergency room Geriatric focus: Alternate level of care, complex continuing care, Geriatric Rehab, Secured dementia unit NP as MRP since July 2011 discharge, July 2012 admissions 3 NPs Interprofessional team (RN, RPN, PSW, OT, PT, Dietitian, SLP, Chaplain, Therapeutic Recreation) NP service available Monday Friday 8AM 4PM LAKERIDGE HEALTH MODEL Date of implementation Number of attending NPs, case load Lakeridge Health July 2011(discharge), July 2012 (admission) Total: 3 (1 Adult, 1 PHC, 1 Adult/PHC) Number of admissions & discharges Over 1000 admissions/discharges 74-78 beds: 3 rd GRU 26 bed 4 E ALC/CCC 24 plus 4 beds West Secured, 24 plus 2 beds Patient selection and profile Frequency of rounding Afterhours coverage, planned and un-planned absences Approach to legislative and regulatory gaps Alternate level of care, Complex Continuing Care, Geriatric Rehab Monday to Friday Hospitalist physician covers evenings/weekends/ holidays Medical directives 7
LAKERIDGE HEALTH MODEL Mentorship and support for NP Access to emergency medical consultation in decompensating patient General reception by colleagues,patients and families Biggest ongoing challenge Biggest success Lakeridge Health NPs/MD Liaison 911 Free standing hospital, no emergency room Pt must transfer facilities Researched - Acorn (2015) pt/family/staff satisfaction, best practices, international accolades, early adopter, supportive of others to get established Sustainability due to no dedicated funding Established and successful, value added NP domains of practice, consistency LESSONS LEARNED Negotiation of after-hours coverage can be challenging may require an agreement with hospitalists if NPs unable to meet on-call requirements. Strong administrative support is critical to overcoming barriers while implementing. (See the presentation on Operationalizing the NP-MRP role for tips on how to build support) This is an enormous responsibility for NPs to take on medically/legally A perceived/actual conflict of interest may arise as the NP is usually a salaried employee of the hospital. This could remove the check/balance that is inherent with the consultant role of MDs. 8
OPPORTUNITIES TO EXPAND THE NP-MRP MODEL IN HOSPITALS Sub-acute units (Rehab, convalescent care, transitional) ALC units or patients Chronic patients in acute units (chronically ventilated patients in ICU) Acute in-patient medicine units Surgical units immediately post-or/pacu FOR ADDITIONAL INFORMATION Montfort : vanessahelleur@montfort.on.ca Lakeridge : michelle.acorn@lakeridgehealth.on.ca St-Joseph : smulsant@stjoestoronto.ca 9
REFERENCE Acorn, M. (2015). Nurse practitioners as Most Responsible Provider: Impact on Care for Seniors Admitted to an Ontario Hospital. International Journal of Clinical Nursing Practice. 2:126. Helleur, V. Desroches, J. Antoun, A. (2017, September 22). Operationalizing the NP MRP in Ontario Public Hospitals. Retrieved from: https://hopitalmontfort.com/en/resources Presentation materials available at: https://hopitalmontfort.com/en/resources 10