1. The Toronto Rehab NP Study: ”Improving access, continuity & quality of primary health care for a community of patients with complex complex continuing care needs”
Presented at the ICN NP/APN Conference, South Africa, June 30, 2006
Linda Dacres, RN(EC), NP-PHC, BScN,
MHSc (Family & Community Medicine), PhD (c)
Consultant, Primary Health Care and Ambulatory Innovations, NP Role Integration
Nurse Practitioner, Complex Continuing Care - Toronto Rehabilitation Institute

2. Introduction
The Primary Health Care Nurse Practitioner (NP) Study explores the extent to which the NP role is implemented at the Toronto Rehabilitation Institute in Complex Continuing Care
Evaluate the NP’s impact on the access, continuity and quality of primary health care
Project Goals
The introduction of the NP role in CCC settings is a new and innovative endeavor undertaken by this project team in the province of Ontario.
The implementation of the NP role in CCC supports the working definition of PHC in that it establishes and enables a sustainable long-term relationship between the interdisciplinary team and the patient.
Because of novelty of the NP role in CCC, the Study was designed to carefully monitor the implementation of the role, attend to factors that could interfere with its appropriate implementation, and to formatively evaluate the NP’s contribution to the achievement of the desired outcomes.
Accordingly, this Study is concerned with introducing the NP, as an integral member of the interdisciplinary team, within a 50 bed CCC unit at the Queen Elizabeth Centre at the Toronto Rehabilitation Institute.
Having the Study confined to one CCC unit will facilitate an in-depth assessment of the value and contribution of the NP role to the delivery of health care in CCC. It is our vision that the lessons learned through this Study will be useful in creating a Nurse Practitioner model for guiding the introduction of other NPs in other CCC units or facilities.

3. Principal Investigators
Karima Velji
Vice President, Patient Care & Chief Nursing Executive - Toronto Rehabilitation Institute
Dr. Souraya Sidani Professor, Faculty of Nursing, University of Toronto
Funding:
Health Canada
Primary Health Care Transition Fund

4. Outline Context: Toronto Rehab Institute NP Role NP study
Preliminary findings
Next steps
Discussion

5. MR

6. Mandate Vision To advance rehabilitation and enhance quality of life.
Mission
We partner with individuals, their families and
supporting communities in innovative, effective adult
rehabilitation and complex continuing care. In affiliation
with the University of Toronto, we lead the integration of
service, research and education, and the development
of a coordinated rehabilitation system.

7. Clinical Programs Cardiac Rehabilitation & Secondary Prevention
Complex Continuing Care Program
Geriatric Rehabilitation Program
Musculoskeletal Rehabilitation Program
Neuro Rehabilitation Program
Spinal Cord Rehabilitation Program
Long Term Care Program

8. Toronto Rehabilitation Institute
Patient Care (Professional Practice) Pillars
Patient Care
Research
Education
To advance Rehabilitation and enhance quality of life
Vision +
Best
Practice
Education
Professional
Excellence
Ethics
Spiritual
Care
Mission
We partner with indivi-duals, their families and supporting communities in innovative, effective adult rehabilitation and complex continuing care. In affil-liation with the University of Toronto, we lead the inte-gration of service, research and education, and the development of a co-ordinated rehabilitation system.
Best Practice/Advanced Practice
Leaders
Education Leaders
Clinical Educators
Corporate Practice
Leaders
Bioethicist
Chaplains
S. Solway (BP Leader)
N. Foster (Cardiac)
D. Driver (CCC)
B. Trentham (CCC)
N. Boaro (Neuro)
L. Spanjevic (Geriatrics)
M. McGlynn (MSK)
J.Ibrahim (Emotional Care)
Vacant (Pain)
Heather Flett (Spinal)
L. Sinclair (IPE -Leader)
L. Inness (PT)
L. Korkola (Nursing)
D. Hebert (OT)
C. Steele (SLP)
L.Ruttan (Psychology)
T. Dion (TR)
N. Rave (Chiropody)
J. Huth (Chaplaincy)
J. Stretton (SW)
E. Rolko (Pharmacy)
D. Wildish (Dietitian).
G. Tardif (Medicine)
B. Secker
J. Huth
P. Stevens
S. Walters
J. Kim (Nur - CCC)
W. Kiersnowski (Nur- G)
M. Gibson (Nur-S)
L. Keats (Nur-S)
T. John (Nur-M)
S. Ram (Nur – N)
K. Brunton (PT)
J. Howe (PT)
D. Hebert (OT)
M. Lowe (OT)
R. Mabrucco (SW)
P. Gairy (Nur- CCC)
Values
We are committed to:
Caring
Discovery
Learning
Collaboration
Accountability
Advocacy
(Jan 5, 2005)

9. Collaborative Practice
Clinical Programs
Best Practice
Education
Professional Excellence
Ethics + Spiritual Care

10. Impetus for NP Study Limited physician access
Improve continuity of care, quality & access to primary health care services
Enhance communication – interdisciplinary & families
Increase response time - decrease emergency transfers & costs incurred to health care system
Impetus for the Study
Recruitment and retention of physicians
Part-time nature of the FP physicians’ contract with CCC units
Few hours spent on units – no financial incentives
Lack of physician expertise in CCC and lack of willingness to practice in this population
Need to decrease the frustration that patients, families, physicians, nurses and other care providers currently experience through the episodic nature of medical care provided by physicians’ due to multiple demands within their schedules
Due to high workload, FP physicians do not have enough time to discuss the comprehensive plan of care
Need for improved access to PHC services including health promotion, prevention and screening programs, and dedicated time to deliver them.
Need to improve quality of care through timely interventions such as early screening and interventions for preventable diseases
Need for improved communication both interdisciplinary as well as with families and substitute decision-makers. Families have expressed the need for more communication regarding changes in the residents’ condition
Need for improved response to acute illness requiring urgent assessment and management; one-third of patients are transferred to acute care for assessment and intervention every year resulting in additional costs to the health care system

11. Purpose of NP Study
To describe the extent to which the NP role is implemented as designed in a CCC setting
To identify the enablers and deterrents for a successful implementation of the NP role in CCC setting, including the collaboration between FP physician and NP
To evaluate the NP contribution to improved
a) Access to PHC for residents in CCC
b) Quality of technical and interpersonal aspects of care provided to residents and families in CCC
c) Communication and coordination of care
among members of the interdisciplinary health
care team.
The Outcome Indicators are:
To describe the extent to which the NP role is implemented as designed in a CCC setting.
NP keeps a record of the services provided on six randomly selection occasions during the 12-month implementation period. This list of services was derived from the NP role description. A research assistant observes the NP on the same six randomly selected occasions for objective monitoring
2. To identify the enablers and deterrents for a successful implementation of the NP role in CCC setting.
post-test interviews with the NP, the physician, the unit manager, nursing staff, and other health care team members with the aim to identify factors that they perceive as having either facilitated or hindered the implementation of the NP role.
To evaluate the NP contribution to improved
Access to PHC services for patients in CCC (A unit communication log is used to gather relevant data )
Quality of technical and interpersonal aspects of care provided to patients and families in CCC (NP will be requested to complete a standardized encounter form where she documents the person requesting the encounter, the reason for it, and the services rendered.
Communication and coordination of care among members of the interdisciplinary health care team. (measured at baseline and post-test, with a subscale of an instrument developed by Shortell et al., (1991). The subscale contains 6 items capturing openness, accuracy, and timeliness of relaying information about patients’ status among health care provider in the unit

12. Complex Continuing Care
224 beds – 6 clinical units
Recent re-structuring
Complex acute and chronic medical and functional neurological needs
10 bed palliative care unit
Multiple & demanding 24/7 health care requirements
CCC Population
QEC is a 224-bed hospital located in the central west end of Toronto on the shores of Lake Ontario. The CCC program provides interprofessional care and patient-focused services for an adult population with a combination of advanced physical, cognitive or behavioural challenges that limits or impairs independent living in the community or in LTC.
The Study Patients who are located on the the South 4 unit of the hospital, have a variety of complex conditions, such as acquired and post-traumatic brain injuries, spinal cord injuries with resulting paraplegia and quadraplegia, infarcts, CVAs and severe hemiplegia, MS, Parkinsons, Organic brain syndromes, cerebral palsy with developmental delay, and carcinomas
Patients have multiple health care needs which demand constant nursing and medical care, and have limited potential of returning to their homes. CCC units become a community of living (home) for these individuals, and a first point of access to PHC services.

13. NP Role Utilizes full scope of RN(EC) practice
Provision of PHC and specialized services to residents &.
Hub of interdisciplinary health care team
Liaison and communications
Counselling and health education
Best-practice implementation
Illness prevention
End-of-life care
Role of the NP (Employed on a full time basis, 5 days weekly – (Exposes to varied hours/ shifts to work with various HCPs and to liaise with families)
Primary responsibility of providing the required PHC and specialized services to residents and their families
Completes admission histories and physical assessments
Initiates comprehensive plans of care, timely provision of care, attendence to evolving and emergent needs, appropriate referrals or transfers to other providers and facilities as required, and provides continuity of care within the CCC setting
Provides surveillance for infection and infectious outbreaks
Specialized aspects of care for this population include issues concerning indwelling catheters, G/J-tubes, tracheo-stomal and airway management, wound management, mobility, and assessment of spasticity.
Psychosocial assessments and evaluation for depression
Advanced directives, palliation and end-of-life care
Monitors for changes in patients’ condition on a daily basis; Conducts comprehensive physical and psychosocial assessments; orders diagnostic, labs and screening tests and interprets the results; makes and communicates a diagnosis; prescribes pharmacological and non-pharmacological agents and orders therapeutics; Maintains communication and continuity of care through follow-up contacts with patients and families; discusses patients’ changing needs and changes to plan of care. Provides frequent updates of patients’ health status
Liaises and consults with the interdisciplinary health care team and allied services in CCC which include RNs, RPNs, HCAs, physicians, pharmacists, occupational and physical therapists, speech language pathologists, chiropists, podiatrists, dietitians, recreational therapists, social workers, and chaplains to ensure timely assessment of the patients’ plan of care, changing conditions and identification of changing needs. Coordinates patient care in collaboration with other health care providers. Makes necessary referrals to specialists and in-patient services
Promotes enhanced communication and coordination of care among the interdisciplinary health care team members.
Provides counselling and health education to patients, families and staff
Participates in best-practice planning and innovation (Nurses Intranet, Health Assessment Workshops - Respiratory Workshop, Infection Control)

14. Study Design Mixed quantitative & qualitative pre-post design
Data collection from multiple sources
12-month NP implementation period
One CCC unit
A mixed, quantitative and qualitative design
Quantitative outcome data will be gathered by 1) reviewing the unit communication log, 2) extracting relevant information from the residents’ charts and facility database, and 3) surveying residents, families, members of the health care team, and the physician and NP at each point of data collection (i.e., baseline and post-test).
The qualitative aspect of the design involves 1) having the NP keep records of the services provided, and 2) interviewing the NP and the CCC unit staff to identify factors that facilitated or hindered the NP ability to implement the role as designed. All patients on the demonstration unit (n=50) and their family members will be approached to participate in the project.
Data was collected from multiple sources: all HCPs, patients, families, SDMs
Process for NP integration: first four months of the project, the NP was oriented to the role by working closely with interdisciplinary team and physicians; role officially began at 4 months with the role implementation (intervention) lasting 12 months….etc
Baseline data on relevant outcomes (i.e., access to care, quality of care, and communication and coordination) will be collected.
Pre-test & post-test data:Post-test data on the same outcomes will be obtained in the four months following this role implementation period

15. PRE-TEST Participants Targeted Recruited Patients 25 17
Families and SDMs 50 32
Health Care Professionals 45 71
Total
N=120
Baseline Report data:
According to the most updated list of South-4 patients admitted on the South 4 unit (requested from unit secretary & unit manager on Mar. 23rd 2005 by ), there were 43 patients admitted on the unit (excluding respite admissions).
Of these 43, only 17 patients are cognitively able to participate in the study.
To date, there are 17 patients in the study who were consented, able to speak and understand English; and who were cognitively able to participate.
Of the 17 patients, 11 families responded and participated.
There are 32 next of kin family member(s) /substitute decision maker (SDM) in the study. Eligibility criteria for family members include ability to speak and understand English and 18 years of age or older.
Different approaches were used including contact by phone, fax, evening and weekend appointments, meetings, flyers, mailed packages, families identified by nursing staff, use of bulletin boards, posting memo on patient’s bedside, reminder calls, follow-up letters etc. for the maximizing the recruitment of family members.
All members of interdisciplinary team, who work on South-4 unit including nurses, physician, therapists, pharmacist, etc., were approached to participate in the evaluation.
There are 61 Health care professionals (Staff) in the study, consented and able to speak and understand English.
Different approaches were used including brief introduction of the study by the principal investigator on multiple occasions, group meetings, individual appointments with staff members, use of communication book, up-to-date posts on bulletin board, attaching a memo to pay stubs, phone contact, s, follow-ups etc.
Of the 61 Health care professionals, there are 37 Nurses (60% of HCPs).

16. POST-TEST Participants Targeted Recruited Patients 25 15
Families and SDMs 50 19
Health Care Professionals 45 41
Total
N=75

17. Preliminary Findings 1. Implementation of NP role
(6) Self assessment and observation of role components derived from the literature
2. Enablers and deterrents
(25) Qualitative interviews
Extent of role implementation: Determining the extent to which the NP role was implemented as designed is essential for refinement of the role description prior to its integration in other CCC units and facilities, and for identifying its contribution to high quality care. The extent of role implementation will be assessed by having the NP keep a record of the services provided, using the list in Appendix B, on six randomly selection occasions during the 9-month implementation period. This list of services was derived from the NP role description. A research assistant will be requested to observe the NP on the same six randomly selected occasions in order to have an objective monitoring of the role implementation. On each occasion, the research assistant will spend two days with the NP and record his/her observation on the same list used by the NP.
2.Enablers and deterrents for successful role implementation: At post-test, one of the investigators will conduct individual interviews with the NP, the physician, the unit manager, nursing staff, and other health care team members with the aim to identify factors that they perceive as having either facilitated or hindered the implementation of the NP role. The interviews will be semi-structured, covering topics related to their perception of the role and its contribution, and to factors that could have interfered with its implementation. Factors related to the demands of the role, workload, autonomy, and acceptance of and support for the role by members of the health care team, have been identified as influencing the NPs’ role implementation in acute care settings (Irvine et al., 2000), and will be used for prompting, as needed. Examples of the interview questions are in Appendix C.
3.Access to PHC services: Access to PHC services for clients in CCC unit will be measured at baseline and post-test. Access to PHC refers to the “provision of the required services by the right provider at the right time”. In this demonstration project, access is operationalized with the number of calls made to physician / NP regarding the residents’ condition; the appropriateness of the calls; and the time between placement of the call and the physician NP response to the call. A unit communication log (Appendix D) will be used to gather relevant data. The unit nursing staff will be requested to document the time a call was placed and the reason or residents’ problem for which the call was made. The physician or NP will be requested to document the time they made the visit to the resident in response to the call. In addition, staff nurses, residents, and families will be asked to rate the extent to which the services were provided promptly. Relevant items are incorporated in the instrument measuring coordination of care.

18. Preliminary Findings cont’d
NP contribution to improved:
3. Access to PHC for residents in CCC
Unit communication logs
4. Quality of technical and interpersonal aspects of care provided to residents and families in CCC
MDS indicators
Standardized encounter tool
Individualized Care Index (van Servellen,1988
5. Communication and coordination of care
Communication and coordination subscales
(Shortell et al., 1991)
4. Quality of technical and interpersonal aspects of care:
The technical aspect of care refers to “the specific services used and the way in which episodes of treatment are managed” (Tarlov et al., 1989, p. 726). In this demonstration project, the quality of NP technical care will be evaluated by 1) Assessing the number, type, and appropriateness of the assessments done, screening or diagnostic tests ordered, pharmacological treatments prescribed, and non-pharmacological therapies prescribed. The NP will be requested to complete a standardized encounter form (Appendix E), where she documents the person requesting the encounter, the reason for it, and the services rendered. The physicians and NPs on the project team will review every 10th encounter form completed by the NP to determine the appropriateness of the services rendered, as compared to those specified in the medical directives. 2) Assessing the rates of the following at baseline and post-test for all clients on the unit: incidence of pressure ulcers, delirium, pain, and depression. Data on these outcomes are collected as part of the Minimum Data Set (MDS) in CCC facilities. These indicators of quality of care will be assessed before and after the NP role implementation will be obtained from the information systems department. The interpersonal aspect of care refers to “aspects of the way clinicians relate to patients” (Tarlov et al., 1989, p. 926). Of interest in this project are the physician and the NP provision of patient counseling and education. This will be measured with a subscale from the Individualized Care Index (van Servellen, 1988). The scale contains 7 items inquiring about the respondents’ perception of the extent to which the health care provider discuss the patients’ condition and plan of care with the patients and their family, and provide them information on ways to manage the patients’ physical and psychosocial problems (Appendix F). The scale has demonstrated acceptable internal consistency reliability (alpha > .80) (Sidani et al., 2003). The scale will be administered to residents and families at baseline and post-test.
Communication and coordination of care: Communication among health care provider will be measured at baseline and post-test, with the respective subscale of an instrument developed by Shortell et al. (1991). The subscale contains 6 items capturing openness, accuracy, and timeliness of relaying information about patients’ status among health care provider in the unit (Appendix G). It demonstrated acceptable reliability (Shortell et al., 1991; Sidani et al., 2003). The communication scale will be completed by HCP on the participating CCC unit. Coordination of care will also be measured at baseline and post-test, with the respective subscale of the instrument developed by Shortell et al. (1991). The subscale contains 9 items inquiring about the extent to which unnecessary delays in patient care were avoided (Appendix H). It is also reliable (Shortell et al., 1991; Sidani et al., 2003). It will be completed by NP, residents and families on the participating CCC unit.

19. Next Steps Complete data analysis and report Dissemination of results
Consultant, Primary Health Care & Ambulatory Innovations, Nurse Practitioner Role Integration       
Nurse Practitioner - Complex Continuing Care
NP role implementation in 4 clinical programs

20. Study Team Karima Velji, Toronto Rehabilitation Institute (PI)
Dr. Souraya Sidani, Faculty of Nursing, University of Toronto (PI)
Dr. James Edney, Toronto Rehabilitation Institute
Dr. John Masgoret, Toronto Rehabilitation Institute
Kathy McGilton,Toronto Rehabilitation Institute
Dr. Gaetan Tardif, Toronto Rehabilitation Institute
Marnie Bowser, Toronto Rehabilitation Institute
Dr. Mary Van Soeren
Moyra Vande Vooren
What outcomes does the NP Study hope to achieve?
Drawing on the success of NPs in increasing access, quality, satisfaction, continuity, and coordination of care in PHC, long-term care, and acute care settings, the Principal Investigators questioned whether the role of the NP by extension was well suited to CCC settings for many reasons:
The specialized knowledge and expertise of the NP who is on the unit is expected to lead to earlier patient interventions when a patient’s condition changes and/or deteriorates. It is posited that the NP will provide not only access to primary health cares services by becoming an integral member of the unit team in the day-to-day management of health problems, but will also make a considerable impact in response time by shortening the interval of time from when a problem is identified and responded to by the NP.
NP interventions will be anticipatory rather than reactive ones. The NP who has advanced assessment skills will be able to detect the early warning signs and symptoms of infections that present acutely in such populations. These predominantly include UTI’s, respiratory infections such as pneumonias related to aspirates, artificial airways and immobility, wound infections, dermatological complications such as cellulitis, irritant dermatitis and eczematous eruptions, and last but not least, bacteremia.
Timely discussions with the NP & off-site physician in emergencies will lead to a co-managed approach and facilitation of more aggressive measures & interventions that will reduce transfers & admissions to acute care hospitals, and hence reducing disruption for families & patients, resulting in a less costly care delivery model.
Better communication with patients, families and members of the interdisciplinary team will result in higher rates of satisfaction and promote a sense of cohesiveness.

21. Acknowledgements Primary Health Care Transition Fund
Program of the Ontario Ministry of Health and Long Term Care Demonstration Project # G
Toronto Rehabilitation Institute
University of Toronto
Alba DiCenso – McMaster University
Michelle Clifford-Middel - Healthpositive

22. For further Information
Contact Karima Velji (PI)
Contact Souraya Sidani (PI)
Contact Linda Dacres, NP