July 7, 2008 It’s a new and innovative way of treating diabetes and the Edmonton-West Primary Care Network (PCN) is proving it works.
Since 2006, the PCN has been using a decentralized care model that places nurses with physicians in their family practices, as part of their clinical team. The role of the nurse is to help patients self-manage their chronic disease.
“We hired nurses from a variety of backgrounds and educated them in caring for people with diabetes,” says Sharon Nelson, the chronic disease management nurse team leader.
Currently, there are 15 nurses in 18 family physicians clinics that belong to the Edmonton West PCN. Nurses see more than 5,100 patients with diabetes.
The nurse complements the care already provided by the family physician and makes sure there is an up-to-date patient assessment. The nurse then meets with the physician to discuss goals and treatment options and ensures that appropriate lab work and screening tests are completed. The nurse also spends time with the patients to help them manage their diabetes and supports the patients with the stresses that can accompany chronic illnesses.
“This arrangement has had a positive impact on patients,” says Nelson. “For example, some didn’t know they needed to change needles in their lancets every time they used them. Others didn’t know they couldn’t use expired insulin.”
“Education is a big part of the nurses’ job. They do a lot of teaching and support and really become a resource for the patients,” says Nelson.
The Primary Care Network nurses are able to fill a gap that physicians don’t have time for.
Early statistics and patient testimonials indicate that patients seen by chronic disease management nurses have reported weight loss, improved glucose control and improved self-management skills.
While the PCN team targeted diabetes initially, because it’s the most prevalent chronic disease, the next step will be to address heart failure, COPD, asthma and obesity.
Nelson admits some physicians were a bit uncertain at the beginning, but their view of the multidisciplinary team working in Primary Care Networks has changed.
“The physicians are embracing the expertise the nurses provide,” says Nelson. “At the start, some were a bit skeptical, but now they’re asking for more and more of the nurses’ time, not less.”
Effective disease management by the health care team, coupled with strong self management by the patient, should result in fewer hospital admissions, fewer emergency room visits and improved quality of life.
In the Edmonton-West PCN there are 64 family physicians in 18 clinics. In addition to the nurses, the PCN team also includes a mental health consultant, dietitian, licensed practical nurse and pharmacist.