New Zealand Nurse Practitioner in Residential Aged Care Dr Michal Boyd RN, NP, ND, FCNA(NZ), FAANP Associate Professor and Nurse Practitioner School of Nursing and Freemasons’ Dept. of Geriatric Medicine
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New Zealand Nurse Practitioner in Residential Aged Care
Dr Michal BoydRN, NP, ND, FCNA(NZ), FAANP
Associate Professor and Nurse PractitionerSchool of Nursing and Freemasons’ Dept. of Geriatric Medicine
o Started in Colorado, USA 1965o Loretta Ford and Henry Silverman
o Began in Australia 2000 and New Zealand 2001
o Australia 1,248 roughly 1 NP/20,000 populationo New Zealand 246
o NZ - 10% older adult focuso NZ – 50% primary healthcare focus
Nurse Practitioner
2
Australian NPo Australia some access
limitation to medicine formulary
o 2010 Australian NP access PBS/MBS
o Previously NPs could prescribe, but with no medicines subsidy
o MBS reimbursement for tests and imaging
New Zealand NPo 2014 authorised Prescriber,
full access to the medicines formulary
o Previously NPs were designated prescribers –limited formulary
o Death certificates soon
o Tests and imaging regional variation
Can, May and Pay
Number of Nurse Practitioners Registered per year in New Zealand
13 3 3
810
14
4
15
22
1416
1821
16
58
34
0
10
20
30
40
50
60
70
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
NZ Nurse Practitioner Registrations
Oldest Old Increasing Proportion of Deaths
Data source: Statistics New Zealand. Historic estimates and National population projections,2014(base)-2068, slide by Prof. Heather McLeod
DHB and Regional Projections National Projections
3
7
12
13
14
17
18
21
24
29
32
32
38
67
57
69
58
58
61
52
57
54
43
51
54
34
31
35
19
30
28
22
31
23
23
29
17
14
28
Korea 2009
Singapore 2006
Japan (Kyushu) 2000-04
France 2005
Ireland 2000-10
Czech Republic 2009
Austria 2009-10
England and Wales 2008
Belgium 2001
USA 2005
Canada (Manitoba) 2006
Australia 2005
New Zealand 2003-07
International Comparison of Place of Death for those >65JB Broad, et al. 2012
Residential aged care % Hospital % Other# incl. own home %
Presenter
Presentation Notes
No data for Australia broken down by these age groups. Several questions… Are the data believable? If true, what are messages? ………… DISCUSS Some differences in definitions – in UK, hospital data include a few NHS care homes ? NZ very high in rescare, but low in hospital deaths. Maybe high rescare is not such a bad thing?
Life CourseApproach to Healthy Ageing
7
Clinical Frailty ScoreRockwood et al.
ELDER 2016: Distressing Symptoms 1 month before death
0
5
10
15
20
25
30
35
depressionevery day
fear everyday
anxiety everyday
agitationevery day
resistance tocare every
day
pain everyday
SOB everyday
SkinBreakdownevery day
Total Cancer Dementia Chronic Illness
NP in Aged Care
Palliative Care
Gerontology
Specialist or Generalist?
A day in the life of aged care NP• 2 sessions per week per facility of 60-80 residents• 10-12 visits a.m. session (3-4 hours)• Some recent examples:
– Vomiting and haematuria– BPSD, Depression, delirium– Seizure disorder management– UTI, Pneumonia, Anaemia, falls– family meetings about ACP and goals of care ( e.g. resident admitted for
palliative care – but did not die)– Admission assessments– Monthly/Quarterly reviews– End of life care– Monthly MDT and GP supervision round
10/07/201711
A systematic review of the effectiveness of advanced practice nurses in long-term care
Donald, et al.J Adv Nurs 69 (10), 2013
• 4 Studies, 15 papers – 2 CNS and 2 NP models• All quasi-experimental• Reductions in:
– depression, – urinary incontinence– pressure ulcers– restraint use, and aggressive behaviours – improved family satisfaction with medical care
12
NP Models in Residential Aged Care
• Secondary Outreach– Employed by district health board– Aligned with geriatricians
• Primary Care Provider– Paid by aged care providers– Aligned with primary care provider
16%13%
24%
59%
69%
24%
All Admissions Medical Admissions Surgical Admissions
1 year RACIP post intervention hospitalisation rate change Intervention Facilities Comparison Facilities
Boyd, et al. Journal of the American Geriatrics Society, Oct. 2014
Staff are less stressed and more supported by having access to a nurse practitioner
• “And then you’d sit and stress should I, should I hold on, should I wait another day before I fax him, and …… Now I don’t have that – I couldn’t imagine having that right now “. (RN)
• “ You know that you have (NP) coming in on this day. Having a sick resident you used to have to monitor him until the GP comes next week or whenever. Now you know that someone is coming”. (CNM)
GP and NP Collaboration
Collaboration and trust are key
“We’ve both got the abilities to do those things (diagnostic investigations, treatment plans etc.) but we have different strengths and weaknesses in different areas really. So I see someone like (NP) with her whole extended role is just incredibly useful for me in that she’s got a lot more experience at working in rest homes”. (GP)
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