Can rheumatology services be supplemented by nurses? Funding it is more possible than you might think.
There is surely no doubt about the workforce shortage we currently face in rheumatology, and the consequences for both our patients and broader society if our healthcare system cannot respond.
While we are all conscious of the desperate need to train more rheumatologists, if rheumatology patients are to continue receiving care from clinicians who uphold data-driven approaches, this alone might not be enough. We will have to supplement it by exploring all avenues, and maximising any opportunities that exist.
Simply put, we will have to get creative.
I’m always interested in reading The Patient Voice in Rheumatology Republic, but was particularly intrigued by Rosemary Ainley’s article, I wish I had known …, where members of the CreakyJoints Australia social media community were asked what they wished they’d known earlier about their condition, symptoms, treatments and more.
That has inspired me to write this article, to share an innovative role we developed at the Gold Coast University Hospital last year.
As we all know, managing patients with rheumatological conditions can be complex and challenging. After diagnosis has been made, it is vital to ensure the patient not only understands the disease process, but also ensure they adhere to medications, monitoring and treatment regimens while being aware of potential side effects. In addition to this, there are multiple other issues to discuss and questions to answer. The pressure on consultation times often means that these discussions can be limited.
Just over a year ago, we decided to address these issues by employing a Clinical Nurse Consultant (CNC) within the rheumatology department at the Gold Coast University Hospital.
Kelly Hollis is an experienced rheumatology nurse and well equipped to address patients’ needs and concerns. Her main role focuses on patient education – we try to ensure every newly diagnosed patient with inflammatory arthritis is seen to review the disease process, their medications and the importance of any monitoring required. She adopts a holistic approach, so other topics such as diet, exercise, smoking and vaccinations are also discussed.
The CNC can also see patients for a variety of other reasons, including monitoring blood results whilst on certain medications (e.g. methotrexate, sulfasalazine), up/down-titrating medications (e.g. prednisone in GCA/PMR or allopurinol in gout) and providing general reassurance for patients feeling overwhelmed with their condition.
Kelly provides these clinical services via telehealth from her home, meaning patients require less time off work in addition to reducing her own petrol and parking costs (not to mention the environmental implications). This model of care also provides easy access for patients in rural and remote areas.
The position is self-funded using Activity Based Funding, a funding method designed to reflect patient complexity and resource requirements that helps ensure that the more resource-intensive a procedure or treatment, the greater the funding it attracts.
To reflect resources used, it employs a standard called a weighted activity unit (WAU), which varies from year to year and between states. There are of course, rules around this funding model, but with careful consideration and planning, it can work very successfully in delivering quality care.
For public, outpatient rheumatology departments, the activity type is classified as a Tier 2 Non-Admitted Service. There is a different WAU for the speciality provided – rheumatology is classed as Series 20.30, nurse education is Series 40 and procedures such as joint aspiration/injection is Series 10.
The WAU will also differ according to type of clinician involved (e.g. Consultant/Nurse Practitioner vs CNC) as well as the mode of service delivery. A telehealth consult has the same price weight as a face-to-face consult, and a telephone consult has the same weight as an email. Each service event must contain therapeutic/clinical content – for example, assessment, examination, consultation and/or education and result in a dated entry in the patient’s medical record.
As I mentioned, there are ‘counting’ rules with all of this that can get complicated, but the basic rule is that regardless of the number of healthcare providers involved, an OPD appointment must only be counted once – one service event may be counted for a patient at a clinic on a given calendar day, i.e. if a patient is reviewed by a consultant, a nurse cannot claim funding for their review if it is on the same day.
Multi-disciplinary clinic reviews can be claimed, but clinicians must be from at least three different professions and the care provided by each unique. For example, if a consultant, a nurse and a pharmacist review the patient at one appointment, this attracts a higher WAU as three different service providers are involved. For more information and specific examples, please see www.ihacpa.gov.au.
So, back to the Gold Coast University Hospital CNC service.
We conducted a survey six months after initiating the service, asking patients for their evaluation. The majority were extremely satisfied, providing comments such as ‘professional advice’, ‘the nurse was well-informed and thorough’ and ‘happy with this service’. Our clinicians are also extremely pleased with the difference the CNC has made to the department, but most importantly with the difference it has made to our patient journeys.
You can imagine my delight, therefore, when I read Rosemary’s article. All the issues mentioned in the article are topics that are covered by our CNC! I feel so reassured that our innovation in providing patients with the CNC service is what they want and need.
In conclusion, we hope this model of care can be replicated in rheumatology departments nationwide to address the needs and concerns of our patients and thereby improve outcomes.
Linda Bradbury is a Nurse Practitioner based in the rheumatology department at the Gold Coast University Hospital and a member of the Rheumatology Republic editorial board.
