During the period of May 5, 2014 - July 25, 2014 I was provided a unique opportunity through the Registered Nurses’ Association of Ontario (RNAO) Advanced Clinical Practice Fellowship (ACPF), to devote clinical practice time for the purpose of understanding RN led care coordination for complex, high needs seniors, who were receiving primary care from the Belleville Nurse Practitioner-Led Clinic (BNPLC). This fellowship was supported by the BNPLC and through the expertise of my mentor, Dr. Tammy O’Rourke. My fellowship has been timely and provided me with relevant preparation for my upcoming Master of Nursing Primary Health Care Nurse Practitioner education. It is my intention to carry this work forward to my future education endeavors, which start in September 2014. My ACPF aligned with the Ministry of Health and Long Term Care (MoHLTC), BNPLC and Quinte Health Link priorities; targeted towards improved care journeying and enhanced patient outcomes for Ontario’s frail and elderly population. This report will summarize key fellowship activities, identify potential outcomes for patient, provider and system levels of care, as well as, provide recommendations for sustaining primary care coordination.

Prior to my ACPF, we did not know which patients at BNPLC were high users of the care system. I began the process of identifying a target population through analysis of case costing reports made available through my local Health Link, which detailed hospital encounters and costing for the 2012-2013 fiscal year. Next, I reviewed the profiles of the highest cost users to suggest inclusion criteria based on complexity of medical conditions, social determinants of health and predictive consideration obtained through provider interaction.

One of my fellowship goals was to develop a comprehensive role description for the “RN Primary Care Coordinator”. The role and process has been assigned exceptional value with regard to health care system reform, but it is poorly defined and has yet to be mapped. Elrich C. et al., (2009) describes care coordination, as a term widely used in primary care circles despite being poorly understood. It was determined early in the fellowship that role definition and clarity would be an important facet of my work.

Informed through practice, provider collaborative and extensive literature review, I developed a comprehensive role description for the RN Primary Care Coordinator. To ensure comprehensiveness and appropriateness, I presented my RN Primary Care Coordinator role description, to my BNPLC provider colleagues and requested content feedback. My presentation served two purposes; I received feedback enabling further refinement of my role description, while simultaneously clarifying my new ACPF role within the BNPLC team.

I devoted ACPF time to exploring system navigation and care transitions in primary care. I visited three community partner sites: the South East Community Care Access Centre (SE CCAC), Quinte Health Care (QHC) and Mental Health Services (MHS). The purpose of these visits was to identify best practices for system navigation and care transitioning. These community partners made the following recommendations which relate to best practices in care coordination: standardized transitioning, current and relevant information sharing, deliberate planning, integrated model of shared care, ongoing and multi-directional dialogue and assessment, patient and provider engagement, flexible planning, efficient and standard documentation, robust care organizations and sectors that function at full scope of practice, clearly defined role and responsibility, and appropriate funding and allocation of resources.

Additionally, I hosted a patient experienced-based design session to learn from BNPLC patient’s previous care transition and health care system navigation experiences; specifically focusing on what has worked, what hasn’t worked, as well as, provided an opportunity for patients to describe their vision of the best possible scenario, for a well supported, system navigation experience. I shared key design session patient feedback with the BNPLC team. Sharing this information with the team was valuable. As a provider collaborative, we were able to identify what we were doing well to contribute to positive care experiences, including: flexible nature of patient appointments, good patient provider communication, sharing of relevant information, realistic expectations, holistic care, continuity and helping patients navigate the care system to receive the most appropriate care.

Based on the recommendations from the patient experience-based design session and provider feedback, we implemented three practice changes. These practice changes included: the creation of a standard referral checklist to improve accurate referral communication; enhanced understanding about Nurse Practitioner provider roles and scope through the provision of education materials for our patients and local community partners; improved booking and follow-up for test results, by confirming the availability of results, for all results--‐pending appointments, ahead of time. A post-design session letter was sent to each patient participant to describe the ways BNPLC providers were working to improve care and to invite additional feedback on the sufficiency of practice changes.

During my early interactions with potential coordinated care patients I learned that these patients were currently experiencing uncoordinated, fragmented, confusing, and at times, overwhelming interactions with the healthcare system. These patients had care coordination experiences that were reactive as opposed to proactive and they were concerned about the limited primary care involvement. Through my fellowship activities, I was able to proactively partner with these primary care patients to facilitate coordination of their care goals and plans. I created a script to guide, educate and invite patients to become partners in their care experience and initiated individualized Coordinated Care Plans (CCP). My script described what patients could expect from their CCP experience. During these initial planning conversations I invited patients to confirm or deny knowledge of the Health Links initiative. Interestingly, not one surveyed patient had comprehensive understanding of the initiative. Through this process I identified, engaged and partnered with ten elderly BNPLC patients with complex needs to facilitate the initiation of their CCPs. Following CCP initiation, I distributed a CCP follow-up letter to patients with an anonymous survey to assess patient defined worth and value of their CCP experience.

As a component of my ACPF I have been able to identify potential outcomes of coordinated care planning for both, my primary care organization and patients. Organizational outcomes resulting from the ACPF included: improved BNPLC provider understanding and exposure to the process of care coordination, primary care coordination capacity development and role clarity, enhanced working relationships and information sharing with community partners, including: South East Community Care Access Centre, Mental Health Services, Quinte Health Care Corporation, North East Toronto Health Link, Quinte Health Link, Health Quality Ontario, bestPATH, Victoria Order of Nurses, Community Care for South Hastings, The Therapeutic Massage Centre and Belleville Integrative Health Centre.

Patient outcomes included enhanced and consistent interaction with the care system. The CCP process has created a therapeutic opportunity to dedicate provider time to listening, generating meaningful dialogue and truly, understanding patient perspective as it relates to individualized care needs and goals for this population. Systematic planning and coordination has contributed to patients receiving more appropriate care and reduced the likeliness of omissions or duplications in the provision of care.

With continued uptake of primary care coordination, I anticipate more efficient and effective allocation of resources as a result of improved partnering, transitioning and coordination of care services and thus, improved care outcomes for each: the patients, providers and care system. To promote ongoing primary care coordination at the BNPLC I have provided updates throughout the ACPF at daily team huddle, organized ACPF lunch-and-learn sessions and created a provider resource binder for quick and convenient access to assessment tools, referral forms and community contacts. Within the twelve short weeks of this ACPF I have witnessed a progressive improvement in correspondence with community partners; early in my ACPF it took weeks to elicit a response from CCAC. By the end of my fellowship experience I was receiving same day follow-up and one Case Manager, had even sent me a patient update totally unsolicited as a courtesy.

The coordination model of care is highly dependent on sustained, robust partnerships built between providers, organizations and patients. Integrating practice and eliminating fragmented, silo-type, care provision will demand a dedicated and deliberate effort across all provider sectors. Ontario’s health spending indicates improved care coordination for the frail and elderly, has the potential to sustain our public care system (RNAO, 2012).

Through this fellowship, I have seen first hand, the patient and system benefits associated with a proactive approach to care coordination in a primary care setting. I am confident that with additional knowledge of the role and process, care coordination is an appropriate function for the primary care nurse coordinator. Given that complex, high needs, patients reflect up to five percent of Ontario’s population but yet consume two thirds of the entire healthcare budget (MoHLTC, 2013); improved coordination of care for patients who use and need the care system most, will yield substantial economic benefit.

The process of composing the proposal and more specifically, refining and then further refining, my learning plan was valuable and essential learning. To anticipate learning and project target dates for clinical practice that had yet to be defined and piloted, proved to be time consuming and challenging. My mentor and provider colleagues were supportive of the entire ACPF process from conception through to completion. I am grateful to have had such an amazing clinical opportunity collaborate with an inspiring group of patients and providers throughout my ACPF experience.

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