Research projects

Re-orientating general practice towards preventative mental health care for adolescents, utilising the practice nurse: A pilot study

Principal Researchers

Lena Sanci1,

Rhian Parker1,

Brenda Grabsch1,

Verity Newnham,1

Fan Yang1, Kelsey Hegarty1,

Jane Pirkis2,

Elizabeth Patterson3,

Susan Sawyer4,

George Patton4

Institution

  1. Primary Care Research Unit, Department of General Practice, University of Melbourne
  2. School of Population Health, University of Melbourne
  3. School of Nursing, Griffith University
  4. Centre for Adolescent Health, Murdoch Children’s Research Institute

Funding

2007

Award Type

beyondblue Victorian Centre of Excellence

Project completion year

2007

Project brief

This project is a stand-alone component of a larger proposal to trial a health risk screening and follow-up intervention to detect and manage or refer young people with depression or related disorders and health risk in primary care. The aims of this project, in two parts, were to develop a:

a) practice nurse led intervention aimed at increasing the access of high risk youth to general practice (Part A)

b) system change process to support this intervention and psychosocial health risk screening of youth in Australian general practice (Part B)

Background to the project: Young People and Primary Health Care

The special health care needs of adolescents have long been recognized. Recent work confirms that psychosocial issues form the greatest burden of disease for young people including accidents and injury, depression and related disorders, tobacco, alcohol and other substance use and unprotected sexual intercourse.  Where mental health problems, risk-taking behaviour, or abuse have already occurred, early detection and intervention has the potential to reduce damage from ongoing harm.  Adolescents report that they welcome the opportunity to discuss health issues such as contraception, substance use and sexually transmitted infection with health care providers and trust their advice. Yet adolescents tend not to disclose their mental health concerns or risk taking behaviours to health care providers unless prompted, related in part to barriers perceived in accessing care such as fears about lack of confidentiality.

The scope for early and preventive intervention

The importance of screening young people for psychosocial risk factors and depression is becoming evident in guidelines that have been produced (eg. beyondblue ‘Clinical Practice Guidelines: Depression in Adolescents and Young Adults’, 2010)). In Australia, the majority of consultations to GPs by 15 to 24 year olds are for physiological reasons (respiratory, musculoskeletal and dermatological). Yet at least 40% of general practice attendees have been found to have a psychosocial problem. Given that most young people visit general practice for health care at least once a year, the GP visit presents an ideal, yet under-utilised opportunity to detect hidden psychosocial health burdens.

The Role of the Practice Nurse

The practice nurse role and efficacy in primary care has been well-established in the UK, US and NZ and a review of available research has shown that nurses can achieve health outcomes that are as good as those of GPs often with superior interpersonal skills. Latest available data show that 57% of general practices in Australia employ a total of 4924 practice nurses (PNs).

System change in Primary Care

Accepting the need for a preventive approach to the primary mental health care of adolescents creates the need for effective methods of integrating this approach into routine clinical practice. A 12 hour educational intervention for GPs (Adolescent Health Care Principles) designed by the Chief Investigator using evidence-based education strategies, was successful in changing GPs’ screening practice. Pathways of referral or treatment for young people with more complex problems were also covered.

Main Outcomes/key project findings

PART A

  • Practice nurses (PNs) are seen by Key Informants (KIs) who work with adolescents as being able to bridge some of the barriers for young people accessing primary care
  • PNs and KIs believed that PNs could have a role in making general practice more youth friendly, as well as providing a linkage role, but this is not clearly articulated in their job descriptions
  • PNs and KIs articulated similar barriers and facilitators of care for young people
  • Both KIs and PNs believe that a linkage role where PNs work with other agencies, schools and health professionals in the care of young people would provide more holistic care for young people. PNs could also provide outreach health clinics for young people. However, PNs are not currently remunerated for this role and this limits the time and care  they can provide
  • PNs believe that conducting health promotion, brief interventions, screening and running youth health clinics could be part of their role if they were appropriately trained
  • The type and content of training needs is fairly congruent with current training offered to primary care professionals allowing for some context specific items
  • PNs wanted training delivered in distance mode with some face to face workshops
  • Practice nurses with appropriate training in consulting skills and adolescent health care principles, in an environment where there are also GPs with experience to work collaboratively with, are able to conduct preventive health checks, including mental health and suicide risk checks and initial management, for adolescents within the general practice setting and conduct a linkage role.  PNs without training were under confident in all these areas.
  • Enablers for practice nurses to undertake these roles include being trained, salaried such that they can also be free to do outreach visits to community agencies and places where young people gather to promote their service and create linkages.
  • There are barriers to practice nurse participation in youth health under some conditions: when the practice does not have division one trained nurses (ie those clinically qualified to undertake direct patient care); when the practice nurse is not interested in young people’s health; when the practice nurse is part-time with limited time to focus on extra interests such as youth health; when all or part of the practice nurse’s income is generated by specific Medicare item numbers which leaves them with no support to carry out new roles with young people in linkage or screening
  • Some resources found useful by the practice that did change were: pamphlet for parents describing the preventive focus for youth and principles of youth friendly care(eg confidentiality); posters on confidentiality and Medicare card application and what general practice nurses and doctors can help with; all pamphlets re risky behaviours and mental health we provided; laminated cards for young people with useful websites and referral information; training for all reception staff in young people’s health and Medicare; written policy for bulkbilling teenagers, training materials (including dvd of bad practice/good practice; resource kit for youth friendly GPs) that could go in their induction pack for new staff
  • Current remuneration for the work PNs do does not allow for working with young people in a holistic way through linking with other agencies and support services
  • There is no recognition that PNs have a role beyond direct individual patient care so that they can be mobile within, and outside, their practice so as to provide a linkage role within their community
  • Fee for service limits the role PNs can play in the holistic care of young people and it is difficult to provide appropriate care for young people within the existing Medical Benefits Scheme (MBS) or Practice Incentive Payments (PIP) framework
  • Time need to be spent with young people in health promotion and preventive health care and this needs adequate funding to be implemented
  • Ideally all practices interested in re-orientating their care toward preventive mental health for young people have the key enablers for change via engagement in a CQI process and continuous monitoring of performance in youth health – eg. Motivation for the goal, change coordinator staff, autonomy and open communication structure and a culture for testing innovation, computer software and IT support that will enable monitoring of performance over time.
  • Practice nurses and GPs benefit from training in adolescent health care principles including mental health screening and initial management techniques.
  • a Medicare rebate item number would enable GPs and PNs to  screening young people for health risk and mental health problems in a sustainable way as the time taken can be funded

PART B

  • Practice nurses with appropriate training in consulting skills and adolescent health care principles, in an environment where there are also GPs with experience to work collaboratively with, are able to conduct preventive health checks, including mental health and suicide risk checks and initial management, for adolescents within the general practice setting and conduct a linkage role.  PNs without training were under confident in all these areas.
  • Enablers for practice nurses to undertake these roles include being trained, salaried such that they can also be free to do outreach visits to community agencies and places where young people gather to promote their service and create linkages.
  • There are barriers to practice nurse participation in youth health under some conditions: when the practice does not have division one trained nurses (ie those clinically qualified to undertake direct patient care); when the practice nurse is not interested in young people’s health; when the practice nurse is part-time with limited time to focus on extra interests such as youth health; when all or part of the practice nurse’s income is generated by specific Medicare item numbers which leaves them with no support to carry out new roles with young people in linkage or screening
  • Some resources found useful by the practice that did change were: pamphlet for parents describing the preventive focus for youth and principles of youth friendly care(eg confidentiality); posters on confidentiality and Medicare card application and what general practice nurses and doctors can help with; all pamphlets re risky behaviours and mental health we provided; laminated cards for young people with useful websites and referral information; training for all reception staff in young people’s health and Medicare; written policy for bulkbilling teenagers, training materials (including dvd of bad practice/good practice; resource kit for youth friendly GPs) that could go in their induction pack for new staff

Implications for Policy and Practice

PART A

  • Current remuneration for the work PNs do does not allow for working with young people in a holistic way through linking with other agencies and support services
  • There is no recognition that PNs have a role beyond direct individual patient care so that they can be mobile within, and outside, their practice so as to provide a linkage role within their community
  • Fee for service limits the role PNs can play in the holistic care of young people and it is difficult to provide appropriate care for young people within the existing Medical Benefits Scheme (MBS) or Practice Incentive Payments (PIP) framework
  • Time need to be spent with young people in health promotion and preventive health care and this needs adequate funding to be implemented 

PART B

  • Ideally all practices interested in re-orientating their care toward preventive mental health for young people have the key enablers for change via engagement in a CQI process and continuous monitoring of performance in youth health – eg. Motivation for the goal, change coordinator staff, autonomy and open communication structure and a culture for testing innovation, computer software and IT support that will enable monitoring of performance over time.
  • Practice nurses and GPs benefit from training in adolescent health care principles including mental health screening and initial management techniques.
  • a Medicare rebate item number would enable GPs and PNs to  screening young people for health risk and mental health problems in a sustainable way as the time taken can be funded

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