The Murray Medical Nurse Practitioner Project

New legislation allowing Nurse practitioners to treat patients and prescribe medicines under the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) came into effect on 1 November 2010. 

Certainly there was angst amongst GPs: we had previously recognised NPs as having expertise within a DEFINED scope of practice. How would this work in GP land, when 50% or more of presenting problems are undifferentiated??  How can NPs be as qualified as GPs? Who takes ultimate responsibility? What can they prescribe? What about after hours? What about test results? What about indemnity issues? etc. etc. 

In response to this conundrum, the RACGP produced a Collaborative Care agreement template and an accompanying guide for collaborative care arrangements in general practice. The template and guide are available  

This is a 'living document' giving guidance to General Practitioners in discussion with Nurse Practitioners, enabling realistic clinical templates to ensure patient safety. We used this document as a focus to set mutually acceptable guidelines and boundaries of care. 

The Murray Medical Nurse Practitioner Project is a pilot 3 year research project which aims to show that we can integrate NPs into a financially self-sustaining role, treating and caring for the elderly in our community and RACFs, but aligned to a Medical Home- Murray Medical in Mandurah-and very much in a Collaborative care model. Our communities are ageing: our practice operates within a community where both the growth of the ageing population at large, exceed state and national averages. Expectations and costs of providing medical care is exponential and probably not sustainable the way things are at present: it is proving increasingly difficult to get GPs to visit the elderly in RACFs: the reasons for this are complex and not just a workforce issue. So perhaps we need a new model? 

The program announced in the 2010-11 federal budget aimed to explore appropriate models of practice for nurse practitioners in aged care that could lead to improved access to primary healthcare services for the elderly, while identifying effective, economically viable and sustainable models of practice.
We were fortunate to be the only general practice out of 31 participating health organisations to receive a grant based on the GP-nurse practitioner model.

Our belief at MMC is that General Practice, its practice teams and their primary health care relationships comprise the foundations of an effective health care system. Collaboration is the key and not fragmentation of care. Our model will succeed only because our NP works alongside experienced General Practitioners. Isolated practice leads to fracturing patient care and ultimately poorer patient outcomes,-and we do not support stand-alone NP clinics. 

Our 2012 model is underpinned by continuity of care and the use of contemporaneous electronic medical records. 

Our focus initially has been with our patients within Mandurah RACFs, where MMC doctors have historically provided clinical services. Patient safety is paramount. Clinical templates in the care of the elderly have been developed at our Practice/individual level to ensure patient safety. Some examples of templates include specific clinical scenarios, e.g. the assessment of skin sepsis, chest infections, falls assessment, appropriate antibiotic/ analgesia use etc. We have also developed a de novo clinical template to ensure clinical safety when patients present with an undifferentiated problem (particularly important as the presentation of acute severe illness can be very subtle in the elderly, and be challenging for the most experienced of us!). 

We have also introduced the concept of virtual ward rounds: all new RACF patients/or clinical issues are discussed formally each month between the partners who are most closely aligned with these patients and our NP. Our GP Registrars are encouraged to become involved. 

We also envisage an increased role for tele-medicine and tele-consultations

In summary therefore, at MMC, we recognise that appropriately trained and skilled NPs may value add to quality patient outcomes within General Practice as applied to aged care,-but within a Collaborative Care structure. 

An objective outcome measure is critical: does the model improve patient care? We will keep you posted! 

Frank R Jones
Senior partner MMC Mandurah

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