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Autumn 2009 | Vol 13 No 1

Innovation

Nurse-led clinics increase access to quality care

By Lesley Young

The day the Sudbury District Nurse Practitioner Clinic (SDNPC) opened its doors, hopeful patients lined up as early as 7 a.m. Founder and clinic director Marilyn Butcher says she didn’t anticipate the demand, given the one small advertisement they put in the community newspaper announcing the opening of the nurse practitioner–run clinic in the summer of 2007.

Still, the turnout made perfect sense, says Butcher. An estimated 25,000 people in northern Ontario’s Sudbury region are “orphan” patients, receiving sporadic medical care at overcrowded walk-in clinics and emergency departments. They are not alone. Statistics Canada estimates that four million to five million Canadians are without a primary care physician. The SDNPC represents an innovative model of health care in Ontario – indeed, a first-of-its-kind clinic run by nurse practitioners (NPs) in Canada – aimed at helping to fill the need.

Given long wait times that often impede timely and adequate mental health and addiction care (estimated in Ontario to be six months for a psychiatrist), Butcher says that NP-led clinics could benefit this vulnerable group of people. According to the Ontario Ministry of Health and Long-Term Care (MOHLTC), NP-led clinics are not only a great way to provide better care; they are also well positioned to educate patients about disease prevention and health promotion and to help them navigate the system. Over the next two years, the MOHLTC plans to open 25 NP-led clinics (three were recently announced for the remote areas of Belle River, Sault Ste. Marie and Thunder Bay), according to MOHLTC spokesperson David Jensen.

“I’ve wondered whether there isn’t an overrepresentation of orphan patients with mental health issues,” says Butcher. She suspects that people with mental health problems are more likely to fall through the one-patient-one-problem policy at many primary care facilities. “Someone with schizophrenia and diabetes is hard to treat in a five-minute appointment,” she says. (The average appointment at SDNPC lasts 15 to 30 minutes.)

Wendy Fucile, president of the Registered Nurses’ Association of Ontario in Toronto, says that mental health patients are often marginalized. “People with mental illness are often the ones who find it most difficult to access care,” she says. “NP-led clinics are another option, an avenue of entry into the system.” In the past decade, most provinces and territories have implemented legislation that allows NPs to operate within their full scope, which includes diagnosis and management of many illnesses and diseases, including mental health conditions, but exclusively within a primary care setting. Ontario is the only province that currently funds NP-led clinics.

At SDNPC, nurse practitioners complete intakes and physical assessments and send patients for diagnostic testing. They diagnose and prescribe medication (although the ability to do so varies from province to province) and monitor stable chronic illness. Many patients will only need to see their nurse practitioner, says Butcher; however, physicians are available for patient and NP consultation when necessary. Because nurse practitioners are not a substitute for physicians, they consult with physicians associated with the clinic for complex diagnoses. SDNPC also makes referrals to its many community partners. When the clinic opens a site in the town of Lively, a mental health worker will be hired. For now, nurse practitioners diagnose, treat and refer mental health and addictions cases accordingly.

To date, the SDNPC has taken 2,500 patients, with a goal to reach 4,500. “It takes time,” explains Butcher. “These people have been without care for many years. They are diagnosed with multiple chronic diseases, often with a mental health component. For example, the rate of depression is high among people with diabetes, so these patients need a number of visits to sort out their issues.” Butcher says that the benefit is a holistic, comprehensive approach to patient management. The trade-off is seeing fewer patients than those ushered through primary care facilities.

Much of the mainstream medical establishment is critical of NP-led clinics, citing concerns about funding and professional qualifications. According to Dr. Sarah Kredentser, a family physician in Winnipeg, Manitoba, and president of the College of Family Physicians of Canada, “Our College fully supports the enhanced role of other health care professions and we respect their skills as members of a team, but we see them working collaboratively within a patient-centred care team.”
Although the SDNPC has faced such criticism, the doctors who collaborate with the SDNPC are nothing but supportive, says Butcher. “Individual physicians realize we are in crisis here, that there are tens of thousands of patients without access to care. Besides, we are a drop in the bucket of the funding that goes for primary care in this province.”