Organizational and System Factors the Influence NP Patient Panel Size in Primary Care Faith Donald, PhD; NP-PHC Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada Canadian Centre for Advanced Practice Nursing Research, McMaster University, Affiliate Faculty Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Associate Graduate Faculty Member INPAPNN Rotterdam fdonald@ryerson.ca August 27, 2018 1
Presenter Disclosure Presenter: Faith Donald Relationships to commercial interests: None Grants/Research Support: Ontario MOHLTC, Grant # 06695 Speakers Bureau/Honoraria: None Consulting Fees: None Other: None 2
Interprofessional Research Team Faith Donald, PhD, NP-PHC, Ryerson University (Co-PI, Study Lead) Ruth Martin-Misener, PhD, RN-NP, Dalhousie University (Co-PI) Jennifer Rayner, PhD, Postdoctoral Fellow, Ryerson University Kelley Kilpatrick, PhD, RN, Université de Montréal Denise Bryant-Lukosius, PhD, RN, McMaster University Nancy Carter, PhD, RN, McMaster University Erin Ziegler, PhD Student, McMaster University Ivy Bourgeault, PhD, University of Ottawa Noori Akhtar-Danesh, PhD, McMaster University Nicole Bennewies, MN Student, Ryerson University R. James McKinlay, Research Coordinator, McMaster University Virginia Viscardi, Research Assistant, McMaster University 3
Objectives Define panel size Explore organizational and system factors that influence NP patient panel size Image Credit: St Budeaux Parish Church 4
Definitions Panel Size Number of patients regularly under the care of a full-time equivalent primary care provider (Murray, Davies, & Boushon, 2007) Used as a measure of workload and productivity (CFPC, 2012) Also known as Caseload or Roster Workload Amount of time that it takes to do activities (Muldoon et al, 2012) Productivity How often the activities occur (Muldoon et al, 2012) Efficiency of work completed during a specific period of time (Glenngård, 2013) 5
Background NP role is increasingly stable in Canada & internationally Attention shifting from quality of care to productivity of provider Balance between attending to needs of individual patients and needs of the whole panel Achieving goals of improved accessibility and improved chronic disease management can seem at odds oaccessibility requires faster patient appointment times ochronic disease management requires longer times to address complex disease and social needs and education about selfmanagement 6
Why Study is Important Lack of data about NP activity and patient panel size to inform healthcare planning and decision-making related to NP workload and workforce needs Questions from funders, administrators, and health human resource planners re: NP activities & patient panel size No studies have directly measured NP activities in primary healthcare (PHC) settings 7
Methods Update of a scoping literature review Case studies in 8 primary care sites, 4 different models of care Waiting room patient survey Time and motion observation Interviews with NPs (n = 18), administrators (n = 9); office managers/receptionists (n = 8); physicians (n = 6) 8
Model for Estimating NP Patient Panel/Caseload Size in Primary Health Care Martin-Misener, R., Kilpatrick, K., Donald, F., Bryant-Lukosius, D., Lamb, A. (2016). Nurse Practitioner Caseload in Primary Health Care: Scoping Review. International Journal of Nursing Studies, 62, 170-182.
Results (N = 113 peer-reviewed articles) Primarily Canada & US since 2010 Common Methods to Determine Panel Size o Administrative data-bases o Work hours & average number patients seen o Past utilization of resources rather than actual healthcare needs Few studies used validated tools to classify acuity levels or disease burden scores This Photo by Unknown Author is licensed under CC BY-NC-ND 10
Productivity Measures (Frequency / Efficiency) Require health human resource inputs to be linked to health outcomes (Evans, Schneider, & Barer, 2010) Measures o Number of providers, new patients, daily patient visits o Wait times o Procedure volumes o Patient panel size o Length of appointment times o Number of patient telephone calls (Koren et al., 2010; Mian & Koren, 2011) This Photo by Unknown Author is licensed under CC BY-NC-ND 11
Organizational Measures (Rhoads et al. (2006) Focus on productivity, e.g., frequency and efficiency Patient visits consistent or changed? Are patients returning because treatment didn t work? New patients are you getting new patients into your practice? Total physician referrals consistent or is the number changing? Diagnoses numbers changing? Average visits per diagnoses how many visits does it take to make a diagnosis? Cancellations or no-show numbers increasing/decreasing? Reasons for no-shows? Average wait time per patient? 12
NP Panel Size Medical homes in US: 800 patients per NP (Phillips et al., 2014) Family Health Teams in Ontario, Canada: 1300 per physician if NP added, panel increases by 800; assumes fully staffed team, 3 exam rooms/physician, adjusted based on patient complexity [SAMI calculated morbidity index (Rayner, 2013; 2014)] Community Health Centres in Ontario, Canada: prorated number of 1137.5 patients divided by the SAMI to get an adjusted panel size for both NPs and physicians (Rayner, 2014a) NP-Led Clinic in Ontario, Canada: 800 patients per NP (DiCenso et al., 2010; Rosser et al., 2010; Thibeault, 2011) 13
Organizational Factors Multidisciplinary team - Equal role status ; Provider capacity pooling NP has own panel Time spent in role components o Direct/indirect patient care o Administrative o Teaching students - Need additional exam room Innovative types of visits (group/video/email) Rural location - longer hours & more pts Multiple locations for NP Type & size of practice setting Number of exam rooms - 2 or more rooms/provider Number & type of support staff Technology (EMR, email, texting) 14
Community Health Centre Example (Dahrouge et al., 2014) Salaried NPs and family physicians in Ontario, Canada NPs provide care for: o More women o Younger patients o More socially complex patients o More off-site visits o More walk-in care Average appointment length (4 types of appointments) o Similar amounts of time in direct care & administrative work o Family physicians: 28 mins (range 22 to 38 mins) o NPs: 34 mins (range 22 to 45 mins) This Photo by Unknown Author is licensed under CC BY-SA 15
Conclusions from Scoping Review Measurement is complex for oproductivity odetermination of patient panel size Current metrics may not capture NP activities Outcomes research was missing in determination of panel size Few systems to track & measure NP activities or outcomes Effects of NP activities need to be known and considered when making decisions about productivity & panel size Accurate databases are needed to identify and describe the number and characteristics of the patients cared for by provider to help determine panel size 16
Factors Affecting NP Activities & Patient Panel Size in Ontario PHC Settings Case Study Observations and Interview Findings 17
Environmental Design and Work-Flow NPs worked 8, 10, &/or 12 hours One room - combined office and exam room Quick tasks / waited in hall for patient to change Escorted patients Took vital signs / did vision tests / etc Often scheduled the next appointment Number of exam rooms: 1 per NP, combined with NP office Cleaned and prepared exam room between patients This Photo by Unknown Author is licensed under CC BY-NC-ND 18
Organizational Factors Multidisciplinary team ohow well they work together to optimize everyone s scope of practice oturf protection and sorting out implications for continuity of care Staff support more likely for physician NP more likely to reserve appointment times for same day/next day for any patient in the whole practice Technology electronic medical records 19
System Factors Education generally prepares NPs for practice; Some recommended an internship year; Some thought family/all ages should be required before adding a specialty Legislation and regulations requirements for a physician signature that waste time and resources and decrease panel size Funding no NP pay raise since 2006 (total 9 years) and increasing responsibilities in primary care settings; $20,000 less pay than acute care; NPs were discouraged and questioned why they stay in primary care 20
Conclusions Factors that influence NP panel/caseload size are complex and include multiple levels Current measures may not accurately capture NP activities NPs should be engaged as informed partners to understand how to optimize care they provide to their patients The holistic approach NPs bring to primary care is valued by patients, administrators, and team members Efforts to optimize NP panel size must balance the need for time invested to achieve patient health outcomes with time saved to achieve productivity outcomes for health care systems 21
Contact: Faith Donald fdonald@ryerson.ca This Photo by Unknown Author is licensed under CC BY-NC 22