March 9, 2000
To: Community Services Committee
From: Commissioner, Community and Neighbourhood Services
Subject:Nurse Practitioner Project
Purpose:
The purpose of this report is to update the Community Services Committee on the successful submission of an Expression
of Interest to the Ministry of Health and Long term Care (MOHLTC), to secure the resources of a Nurse Practitioner for a
two-year period of time. The report will also advise Committee members regarding the expected positive impact on
resident care and clinical outcomes as a result of this award.
Financial Implications and Impact Statement:
The two-year Nurse Practitioner Project is 100 percent funded by the Ministry of Health and Long Term Care, up to
maximum allowable amounts as set by the MOHLTC. It is anticipated that written confirmation from the Minister of
Health will be received by the Homes for the Aged by March 17, 2000. However, MOHLTC staff responsible for the Nurse
Practitioner Project have confirmed that there will be funding in 2000 for one-time start-up costs, up to a maximum of
$10,000.00. In addition, MOHLTC staff have confirmed that they will fund operating costs to a maximum of $94,500.00 in
each of the two budget years affected by the project.
There is a zero net impact related to this project.
Recommenmdations:
It is recommended that:
(1)the Homes for the Aged Division be authorized to conclude negotiations with the MOHLTC, on a priority basis, to
secure the services of a Nurse Practitioner for the approved two-year project;
(2)the Homes for the Aged Division's gross expenditure budget for 2000 be increased by the amount negotiated between
the Division and the MOHLTC, in an amount not to exceed $104,500.00;
(3)this report be referred to the Budget Advisory Committee for consideration as part of the 2000 budget process; and
(4)the appropriate City officials be authorized and directed to take the necessary action to give effect thereto.
Background:
In early 1999, at the request of the Ministry of Health and Long Term Care (MOHLTC), an Ontario Nursing Task Force
was asked to submit recommendations to the government to address the future needs of Ontario's nursing profession. As
part of the government's response to the Nursing Task Force's report "Good Nursing, Good Health - An Investment for the
21st Century", the MOHLTC created 106 Nurse Practitioner positions, to address the health care needs of rural, northern,
and underserviced areas. The MOHLTC determined that 76 Nurse Practitioners would be funded for underserviced areas,
20 for pilot projects in long term care centres, five (5) for aboriginal health access centres, and five (5) for primary care
networks.
Nurse Practitioners are nurses who are registered with the College of Nurses of Ontario (CNO) in the Extended Class. They
have taken additional training in certain areas to qualify as Extended Class nurses. In February 1998, Bill 127, The
Expanded Nursing Services for Patients Act, became law. This legislation amended the Nursing Act allow Nurse
Practitioners to perform certain clinical services within an interdisciplinary health care team, such as:
(1)diagnosing common ailments such as pneumonia and urinary tract infections;
(2)prescribing certain drugs limited by regulation; and
(3)ordering specific diagnostic, ultrasound, and other laboratory tests.
The Nurse Practitioner has advanced knowledge and decision-making skills in assessment, diagnosis, and health care
management. She/he has the authority to independently perform additional controlled acts as outlined in the CNO's
Standards of Practice for Registered Nurses in the Extended Class.
Within long term care, a Nurse Practitioner is able to work as a primary health care provider, a consultant to the care team,
an educator, and a leader. She/he can provide primary health care services to residents, including: performing
admission/annual history and physical exams, diagnosing some acute health conditions, investigating sudden changes in
resident's health status, ordering and interpreting diagnostic testing results, diagnosing and participating in the management
of human responses to actual and potential health problems (e.g., confusion, aggression), and working with the
interdisciplinary team to improve resident care.
In October 1999, the MOHLTC issued an "Expression of Interest and Qualification for Nurse Practitioners (Registered
Nurses in the Extended Class) in Long Term Care Facilities Project". Long term care facilities were invited to submit
proposals to qualify to participate in a fully MOHLTC-funded two-year pilot project, to evaluate the benefit of Nurse
Practitioners in long term care settings.
The Homes for the Aged Division submitted a proposal related to this project, and was advised by the MOHLTC on
February 24, 2000, that the proposal was successful. As a result, the MOHLTC is committing to fully fund one (1) Nurse
Practitioner (and all associated costs) for an initial period of two years, participating in a joint evaluation to determine
whether there is a permanent role for Nurse Practitioners in long term care. If this joint evaluation confirms that there is a
legitimate, cost effective role for Nurse Practitioners in long term care, there is potential for the project to be confirmed in
permanent health care funding.
The Nurse Practitioner will be funded outside of the Homes' usual base funding formula and will be an additional resource
to the medical staff contracted as Medical Directors and Attending Physicians to meet residents' medical care needs, and to
the nursing staff already employed within the Homes for the Aged.
This report outlines the salient points of the Division's proposal and describes the next steps in implementation.
Comments:
A.Proposal
The Division's proposal detailed the steady increase in acuity levels of residents since 1993, advising that the medical staff
in the Homes describe residents as having multiple, unstable chronic diseases exacerbated by acute medical episodes. The
proposal acknowledged that the care teams have effectively managed care guided by the medical treatment plan, but that
the Homes have identified increasing gaps in proactive interventions with residents experiencing circulatory problems,
respiratory diseases, and psychiatric disorders in particular. The proposal identified that these gaps could be better
addressed by increasing indepth comprehensive assessment, care planning, education, and consultation.
The proposal viewed the Nurse Practitioner as key in developing, implementing, and evaluating evidence-based care
through the further introduction of clinical practice guidelines for the management of chronic conditions such as
continence problems, skin integrity problems, and behavioural management problems.
In the original submission, the Division applied for two (2) Nurse Practitioners. The proposal requested one Nurse
Practitioner to work with the medical staff and care teams at Castleview Wychwood Towers, and one to work with the
medical staff and care team at Albion Lodge. The proposal detailed the differing aggregate residents' profile in each of
these Homes, and identified why a Nurse Practitioner would add value to the care teams and treatment/care outcomes.
On February 24, 2000, the MOHLTC announced the successful bidders for the Nurse Practitioner resources. There were 80
submissions (some with multiple requests) for the 20 available Nurse Practitioner resources. In awarding the 20 resources,
two Nurse Practitioners were awarded to facilities associated with the MOHLTC Central Region Office (Toronto area).
One Nurse Practitioner was awarded to the City of Toronto's Homes for the Aged Division, with the suggestion that this
resource be shared between the two identified Homes, in order to maximize the positive outcomes (both clinically and in
terms of evaluating the benefits of the Nurse Practitioner role). The Division agreed with this request, and is delighted to
have been selected as one of the organizations to demonstrate the effectiveness of the Nurse Practitioner in long term care.
The Medical Directors and Directors of Nursing at the two Homes are committed to working towards the most appropriate
model that will deliver the best outcomes. Through this shared role, the Nurse Practitioner will provide primary health care
services directly to a caseload of residents with psychiatric, psychogeriatric needs exacerbated by chronic diseases and
episodic acute medical problems. With expanded knowledge in prescribing diagnostic investigations and facilitating the
diagnoses and treatment of illness, the Nurse Practitioner is expected to create efficiencies in care, enhancing prompt
response to resident needs and promoting resident comfort and quality of life. The Nurse Practitioner is expected to serve
as a bridge to link the expertise of medicine and nursing.
B.Implementation
The Division is currently initiating its recruitment and selection process and is hopeful that a Nurse Practitioner will be on
site by the end of April 2000. Steps to be taken to ensure effective implementation are summarized below:
(1)confirm all funding and service agreement requirements with the MOHLTC;
(2)enter into the required service agreement (contract) with the MOHLTC and the Nurse Practitioner;
(3)secure the requisite supplies and equipment to enable the Nurse Practitioner to fulfil his/her role;
(4)arrange for the Nurse Practitioner to attend the May 2000 orientation for Nurse Practitioners being arranged by the
MOHLTC for all successful sites; orientation will likely include the participation of the sites' Medical Directors and
Directors of Nursing on the first day of orientation, in order to improve the individuals' understanding of the mutually
supportive roles of Physician, Nurse, and Nurse Practitioner;
(5)orient the Nurse Practitioner to Castleview Wychwood Towers and Albion Lodge;
(6)finalize an evaluation framework to be used throughout the two-year period;
(7)create a mechanism for ongoing assessment and evaluation, involving key stakeholders in each Home, including but
not limited to the Medical Director, Administrator, Director of Nursing, the Nurse Practitioner, and the Division's Manager
of Resident Care;
(8)work collaboratively with the MOHLTC to arrange and maintain an information network for the 20 Nurse
Practitioners approved for long term care within Ontario; and
(9)participate in the MOHLTC required reporting and evaluation processes.
Conclusions:
The Homes for the Aged Division is thrilled that the proposal submitted in response to the Expression of Interest for the
Nurse Practitioner Project was selected and approved by the MOHLTC for an initial commitment of a two-year
demonstration project with full MOHLTC funding. The Division is convinced that the Nurse Practitioner is an appropriate
role to introduce in long term care, and that residents will receive enhanced care as a result of this new resource.
The expected benefits of the Nurse Practitioner role are: more consistent and expanded assessment, earlier identification of
potential health problems, earlier initiation of effective care strategies, and improved collaboration between medicine and
nursing to achieve positive clinical outcomes. The Nurse Practitioner will augment the current roles of the medical staff,
who are on site on a visitation basis only, and the registered staff who do not function under the Extended Class
designation.
The Nurse Practitioner will add value to the Division's care provision programs and to the residents' quality of life.
Contact:
Marsha Nicholson, Manager of Resident Care
Tel: 392-8488; Fax: 392-4180; E-mail: mnicholson@toronto.ca
Sandra Pitters
General Manager, Homes for the Aged
Shirley Hoy
Commissioner, Community and Neighbourhood Services
