Public funding to support the employment of nurses in general practice commenced 22 years ago. Since that time, the primary health nursing profession has witnessed a remarkable surge in growth. In 2003, it was estimated that 2,349 nurses worked in Australian general practice. By 2019, the number had grown to 55,700 – an increase of over 2,000%! The profession has also grown professionally, with support from its professional association APNA and other nursing bodies. Despite this growth, nurse clinics in general practices remain the exception rather than the norm and there remain huge opportunities for nurse leaders to tackle population health challenges in their communities if they have the support of practice owners.
A nurse clinic is a health service where nurses (usually registered nurses or nurse practitioners) take on a more independent and expanded role. Nurse clinics operate within various healthcare settings including, primary care practices, schools, prisons and hospitals.
Nurse clinics focus on specific health issues or patient populations. Examples include youth clinics with a focus on mental and sexual health; chronic illness clinics; First Nations clinics; and women’s health clinics. There is often a focus on best practices and enhancing patient access. The role of nurses in nurse clinics can vary depending on their scope of practice; however, collaboration with medical practitioners and others is usual.
Between 2017 and 2022, APNA was funded by the Australian Government to trial the establishment and evaluation of a number of nurse clinics.
Larter has evaluated the financial viability of 13 of those nurse clinics across three Australian states.
One core obstacle hindering the establishment of nurse clinics in primary care settings is the lack of funding. Registered and enrolled nurses are ineligible for Medicare provider numbers. Consequently, they heavily depend on incorporating GP work and billing or seek funding from their employing practices. Moreover, the existing four categories of Nurse Practitioner time-based items are widely recognised as insufficient. A much-awaited partial remedy is the Commonwealth’s commitment to increase NP rebates by 30% on July 1, 2024; and MyMedicare may also offer opportunities.
To compensate for the current difficulties, a number of other things “need to go right”.
We found there are six key “levers” that need to be pulled to improve the financial viability of nurse clinics, as shown in the diagram below.
- Appropriate billing model – Nurse clinics that were able to use specific kinds of MBS item numbers (in particular chronic disease care plans and health assessments) were more likely to be financially viable. Nurses organised care systems to that more MBS items could be claimed under GP provider numbers. Practices that spent time up-front thinking through their billing model were more financially viable. Some practices charged a patient copayment for specilaised services, such as iron infusions, but the more important factor for financial viability was ensuring an effective mix of MBS claims.
- Robust patient identification and follow up – Correctly identifying the ‘right’ patients to invite into the clinic, and then following them up regularly, was key to generating the throughput needed.
- Timing and size – External ‘shocks’ such as losing a lead nurse, a pandemic, and natural disasters can halt nurse clinics due to the need to reprioritise. Larger practices were more likely to be successful because they have backup staff and/or dedicated management support and can respond better to shocks. Smaller practices that lost their lead nurse or admin (illness, turnover) found it very difficult to sustain nurse clinics.
- Type and organisation of nurse clinic – nurse clinics that were able to offer appointments throughout the week rather than in dedicated sessions or days tended to be more viable, as patients could be slotted into appointment times that suited them. If both a lead nurse and GP were passionate about the nurse clinic’s focus, this helped. And again, nurse clinics that attracted high remuneration MBS items were more likely to be viable. Some clinics charged patient fees, though this usually wasn’t a key determinant of viability unless those fees were for specialist services e.g. iron infusions.
- Professional development – Nurse clinics invested heavily in nursing professional development. However, those that also focused on developing the role of GPs in nurse clinics performed better financially as GPs were more engaged. Protected time for at least two nurses undertaking training was important.
- Teamwork – Nurse clinics sometimes essentially entail the transfer of care from external medical specialists into primary care, changing team dynamics. Principal GP and manager support for the nurse clinic to navigate these challenges was important. Pharmacists and allied health helping identify patients that could benefit were positive.
Somewhat surprisingly, we found that GP time was not ‘freed up’ by nurse clinics – there was no direct substitution. Rather, nurse clinics enabled practices to offer more specialist services and spend more time with their patients.
Larter has extensive experience providing health sector support and using collaborative approaches to developing new models of care, in order to generate better health outcomes for local communities.
Are you a service model commissioner, nurse leader or medical practice owner? Contact us today to discuss your model of care and commissioning needs. Together, we can make a meaningful difference in the health of local communities.