APNA's definition of primary health care nursing covers health, scope of practice, primary health care, roles and settings. We also explore general practice nursing and Phillips et al. six roles of the general practice nurse.
Hepatitis C Clinic
CLEAR (Community Liver Education Assessment and Review Service) is a nurse clinic which provides a free and confidential service for people living with Hepatitis C. It is located in the suburb of Box Hill, Melbourne. It is a partnership between Eastern Health (a tertiary hospital) and Carrington Health (a community health service).
“We already have an existing relationship with Eastern Health. So that makes things easier… We know there is a lot of people who are diagnosed with Hep C who are not linked into any services and will be a challenge for us to treat.”
The community based clinic provides accessible, timely and appropriate treatment to people with Hepatitis C. The clinic supports clients to access new treatment (where appropriate), and also prevents further complications and disease progression.
“The objective of the clinic was to engage the clients that have difficulty engaging at a tertiary centres.”
The name CLEAR was purposefully chosen. Carrington Health wanted to increase patient access to the service. They were concerned a name relating to Hepatitis C would deter patients, due to the stigma associated with the disease.
See how the CLEAR clinic applied the building blocks in establishing their clinic
See the patient flow for the CLEAR clinic
A clear plan
Carrington Health designed CLEAR in response to the listing of new direct-acting antiviral medicines on the Pharmaceutical Benefits Scheme in 2017. The goal of the clinic was to provide treatment for patients with Hepatitis C in a community health setting (rather than a tertiary setting).
Linking to pathology services and co-locating a gastroenterologist at Carrington Health was crucial to the success of the program. Support from the management team at Carrington Health was also a strength of the clinic. They led a lot of the negotiations, such as developing the contracting arrangements with Eastern Health.
Lilee, the nurse leading the clinic, made links with potential referral agencies, such as correctional health and local drug and alcohol services. She also liaised with external health services that would provide the necessary pathology, radiology, and GP services. Lastly, Lilee developed the clinical pathways outlining the appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for patients.
Establishing the clinic took longer than expected, as systems and processes needed to be established between Eastern Health and Carrington Health. This included developing a Memorandum of Understanding (MOU) and finalising processes and procedures to ensure patient confidentiality and the use of patient files.
“With any development of services and when you are working with two separate organisations, with two separate budgets, there are a lot of things to be taken into consideration… It’s just the nature of how it can be when you’re working at separate levels; Eastern Health being a bigger tertiary hospital, Carrington being a smaller community health service. In order to work together we have to meet in the middle.”
CLEAR was commenced with some support funding from the Australian Primary Health Care Nurses Association (APNA), as part of the clinic's involvement in the APNA Enhanced Nurse Clinic project. Now established, CLEAR is funded through existing Medicare Benefit Scheme items, as well as block funding received by Carrington Health.
“Eastern Health bills [patients] through MBS.”
Location and facilities
CLEAR operates from Carrington Health fortnightly, for half a day. The clinic uses two consulting rooms; one for the nurse and one for the specialist.
“We don’t infringe on each other’s space and we can do our own assessment.”
Staffing and HR
The clinic is staffed by an experienced registered nurse employed by Carrington Health and a gastroenterologist employed by Eastern Health (co-located at Carrington Health).
The nurse at Carrington Health has built her knowledge and skills in relation to Hepatitis C to increase their confidence in working in the CLEAR service. Mentoring and shadowing also occurs. The nurse educator from the Eastern Health liver clinic comes to Carrington during the CLEAR clinic and mentors Lilee. Developing a relationship with the clinical nurse specialist at Eastern Health has been key to receiving referrals.
“The nurse consultant (at the liver clinic) has been fantastic to deal with. She is just so supportive. She’s just great. Without her I think we would have even bigger challenges”.
CLEAR also utilises the hospital pharmacy. The pharmacy can arrange medication to be picked up or couriered to the person’s home. In addition, the nurse at EH can take the opportunity to provide education to the patient while taking them to the pharmacy.
“We find it's working very well. Because a lot of local pharmacies don’t have the medication in stock.”
The clinic also utilises best practice guidelines including ASHM’s resources (the peak organisation of health professionals in Australia and New Zealand who work in HIV, viral hepatitis, other BBVs and sexually transmissible infections). They also refer to Australian Department of Health’s National Hepatitis C Strategy.
The model for care for CLEAR was developed utilising the experience from established clinics. For example, an assessment form was developed for CLEAR based on Eastern Health’s nurse led clinic in Healesville.
A key to the program in being patient centred, holistic and being as easy to access as possible. A holistic assessment is conducted and patients are referred to other services as identified (e.g. dential). Patient education is tailored to a patient’s particular needs.
“If the person has alcohol issues we talk to them about the risk of taking alcohol and taking medication. We give them options to (manage their alcohol use)”
The clinic aims to engage people in the local community with Hepatitis C. Carrington Health already provides a number of services to at-risk community members, such as people using drugs and alcohol. They considered that this cohort would be easier to engage in a community setting, rather than a hospital environment.
There are numerous referral points to CLEAR. These include:
• Carrington Health’s needle and syringe program (NSP).
• Self-referral: Potential patients can drop in to reception or phone
• A formal referral from GPs.
• Primary health care services- such as drug and alcohol services and correctional health.
“Whoever wants to come is welcome to come.”
“We have a 1 hour roster per week at NSP. So if I see someone at NSP who has Hep C so just have a quick chat. Quite informal.”
After an initial consult, if required, patients are provided with the relevant pathology forms and a request for a referral from their GP.
There is a direct phone line to the clinic so patients can easily contact the nurse for any inquiries or concerns.
“It is a very flexible clinic. People can come in without any referral initially.”
A challenge has been patients not attending their appointments. This is due to the readiness of the client to commence treatment.
“We really want to build this clinic up to be a friendly and safe place for people to come.”
Systems and processes
The clinic utilses existing processes and systems already in place at Carrington Health including safety, confidentiality, and booking appointments.
“We use all of Carrington’s procedures. In terms of safety, in terms of other aspects of running the clinic.”
The reception staff are a key access point for patients to the clinic.
The clinic model has been adapted and changed over time, to assist in meeting the needs of those attending, and also their partnership with Eastern Health. Usually the patient sees the specialist following an assessment by the nurse, or sometimes they may perform the assessment together if indicated. Generally patients will be followed up by phone. Some patients will attend Carrington Health if that is their preference.
Being flexible and placing an importance on engaging and developing a rapport with patients, has been important in increasing access to care for those attending the clinic.
“I say come in and we will have a chat. I find I’ll lose them when I say that [go get a referral].”
Each service provider uses their own client management system. Lilee enters nursing notes on TrackCare (Carrington Health’s medical records software). Protected administration time allows the nurse to enter the client details into the Carrington’s clinical software and following up with other administration tasks.
“It can be very very rewarding... Days where we have a full clinic. We were so busy. It’s exhilarating.”
Evaluation and improvement
CLEAR utalises Carrington Health’s quality improvement systems. For example feedback forms and box at reception. Increasing inquiries is an indicator that the clinic is acceptable and accessible to patients.
“Obviously somebody is talking because we are getting a lot more inquiries.”
More data will be collected once the clinic has been further established. The clinic is just commencing reviews of their first patients, which may provide an avenue for evaluation.
“This will be an opportunity to look at quality and service and satisfaction.”