Practice Area: Complex Care Transition Program
Years of Practice: 3 years as an NP
What prompted you to consider moving into an Advanced Practice role in Nursing?
I was tired of working in a world of bureaucracy and seeing so many gaps in the health care system. My experience as an RN was working in the hospital, tele triage and then, most recently, public health which I thoroughly enjoyed but couldn’t foresee spending the remainder of my career there. So, I returned to school to pursue an Advanced Practice Role in Nursing with a plan to work in primary care and hopefully help improve patients’ experiences while having a bit more autonomy and decision-making ability.
Why/How did you make the transition from RN work through your advanced degree and into NP practice?
I think the biggest adjustment from RN to NP was the diagnostics and prescribing. The rest was just an extension of listening and caring for people.
What does your typical day look like?
Most of my days involve at least 1-2 home visits providing a comprehensive geriatric assessment, development of a plan, and then depending on the patient needs, optimizing medications, setting up labs and other diagnostic investigations and documenting a report and plan and sending it to their primary care provider. Other parts of my day are telephone or in person follow-up assessments, consulting with home care and other specialists involved in their care and discussing concerns or care with patients and families. Some patients have been home bound for months or years and will never be able to go out to see their family doctor and I have become their primary provider. Occasionally, I follow these folks until they become palliative and until end of life.
Can you tell us a bit about your clinical environment (e.g., where you work, with whom you collaborate, etc).
Besides my direct team, I collaborate with mental health agencies, home care providers, palliative care experts, hospice providers, family physicians and specialty physicians, social workers, and community agencies supporting seniors.
Describe one significant learning about the role of the NP within your current practice environment.
A significant learning about the role of an NP in my current role was becoming familiar with the care of frail seniors. My prior experience was in critical care and then with newborns and young families. Now I am developing skills in assessment and treatment of seniors in the community who often are homebound, who have difficulty getting to appointments, and are unable to get out for diagnostic tests and blood work. They have limited income and may be unable to pay for expensive medications, have multiple chronic complex medical conditions and maybe transportation to a clinic or for groceries is near impossible. I am learning about community resources, seniors’ services and, most importantly, I learn from my patients every single day.
How does your role fit within established health care roles in your work area?
I work in the central office of the Primary Care Network (although my office is my dining room since COVID) in collaboration with the patients’ physician and within a multidisciplinary team consisting of pharmacists, an RN, OT, and OT assistant. I go into patients’ homes to complete the comprehensive assessment and then navigate everything involved in medical management virtually based on their individual needs. I work closely, cross referring to the OT on my team when the patients also have functional needs.
What is one thing you wished you knew before starting in your current position? Describe the challenges you face in your position.
There are many challenges in my position, not even considering the medical challenges with multiple chronic conditions. Most everything I do must be brought to the patient’s home or at least takes much organizing. For example, if someone needs a chest x-ray or pulmonary function test, part of my role is making that happen, either with organizing transportation or arranging portable x-ray to go to their home (at the patient’s expense). I rely a lot on history and clinical assessment at times when diagnostics are just not possible.
What research or teaching are involved in your current role? (non-clinical work).
I am involved in education of other disciplines of the PCN around the care of complex primary care in the community. I also work in a leadership role of the Complex Care Transition Program.
What is something that all NPs can learn from the work you are doing in your current environment?
I think other NPs can learn about flexibility and adaptation from my current role as this appears in my daily care.
What is one thing that you think NPs should be pursuing, as a group of professionals working towards the future of healthcare in AB?
NPs in Alberta should work toward a better funding model.
What do you feel is unique about your practice role?
The Complex Care Transition program is a unique program as it is one of the only outreach programs with a goal to prevent hospital admissions in vulnerable, mostly frail older adult populations.
What do you feel is the biggest impact of the role of the NP in your practice setting?
The NP in this program provides the primary care in the home and helps bridge the gaps between their physician clinic and hospital. Most of these people would not be able to receive care any other way.
Advice for NP students who want to work in your field?
This is an area that is always challenging, fluid and frequently complicated but also rewarding. The sweet seniors are usually very appreciative of the nursing plus medical supportive care.