Patients in Focus 2008 Innovation Category Winner - A Nurse Led Clinic in Primary Care for Patients with Inflammatory Arthritis

04/09/08 : Benny Harston, Nurse Practitioner, Hoveton and Wroxham Medical Practice, Norfolk

		Benny ( on right)) with her OT colleague I am a Nurse Practitioner working in Primary Care. In 1994 my Occupational Health colleague and I set up a small clinic which we decided to dedicate to our patients with arthritis. The aim of this clinic was to ensure our patients were receiving holistic timely care alongside their care for other co-morbidities. We feel the focus of future services should be on quality and equity of services and hope that, by disseminating the small but successful progress we have made to other nurses working in primary care, this will go some way to achieving this aim.

In primary care about 25% of presentations relate to muscular-skeletal problems so the more we focus on this area the better for patient care. Considerable progress has been made in the management of rheumatoid arthritis (RA) over recent years. Emphasis is now on making an early diagnosis of RA. In a practice of our size we expect to see 8 new presentations of RA each year and one of our aims is to ensure that these patients are assessed early and referred in an appropriate and timely manner. We also recognise that our other key goal is to support those patients with existing inflammatory conditions and ensure they have physical and emotional support and access to appropriate services.

We have many patients on Disease Modifying Anti Inflammatory Rheumatology Drugs (DMARDs). These patients need to be monitored at regular intervals. This is a good opportunity for nurses working in primary care to identify these patients and to assess their risk factors for ischaemic heart disease (which is an independent risk factor for patients with RA), monitor for infections, ensure vaccinations are up to date (especially for pneumonia and influenza), deal with flares, pain management and look out for uncommon, but serious, extra articular manifestations of RA such as vasculitis and the development of malignancy. By promoting a clinic-based care of these patients we feel that these factors are dealt with in a timely manner and more organised process.

We have found that patients like being able to get comprehensive care in practice. We have developed excellent working relationships with the local rheumatology service at the Norfolk and Norwich University Hospital and we find that we reduce hospital appointments: by taking on the follow-up care of many of our patients we free up consultant/hospital appointments and improve the patient journey.

We have also held several patient information evenings, where we were fortunate in having various Consultants from the local hospital come to talk about different aspects of RA. The last one was attended by 45 patients and the networking was one of the main strengths of the evening.

By disseminating information to other nurses working in primary care we hope that there will be more practice-centred holistic care for patients with inflammatory arthritis, enabling early diagnosis to be made and thus allowing timely intervention to prevent the problems that inflammatory arthritis can cause to patients’ lives.

Protocol No:

PR77 RHEUMATOLOGY PROTOCOL

Aims

   1. To enhance the illness-related quality of life of those with inflammatory arthritis.
   2. To control disease activity and minimize loss of physical function.
   3. To optimize self-management of the illness in line with NHS policy to support people with long-term conditions (Department of Health 2005).
   4. To achieve the Arthritis and Musculoskeletal Alliance (ARMA) standards of care for those with inflammatory arthritis (ARMA 2004).
   5. To comply with the British Society of Rheumatology (BSR) (Kennedy et al 2004) and NICE guidelines.

Objectives

   1. To provide structured follow-up for those with an established diagnosis of inflammatory arthritis and an individualized care plan.
   2. To provide preliminary assessment of those with suspected inflammatory arthritis.
   3. To provide review within 1 week in cases of deterioration or ‘flare’.
   4. To provide ongoing access to information and advice.
   5. To provide education about the disease process and ways of managing it.
   6. To ensure adequate pain relief.
   7. To ensure access to treatment in line with the latest guidelines by arranging investigations and ensuring prompt referral to a rheumatologist or allied health professional when indicated.
   8. To develop a close working relationship with the local rheumatology services and work to protocols agreed with them.
   9. To provide psychosocial support by engaging in discussion about the effects of the illness on the individual patient and how these might be mediated e.g. family and employment issues, benefits.
  10. To provide access to recognized education programmes.
  11. To involve family members, where appropriate, in education and discussions about the illness.

Target Population
All patients with inflammatory arthritis.

The service will provide:-

   1. Formal medical follow up that substitutes for secondary care follow up for all those who have a diagnosis of inflammatory arthritis and who are currently taking first or second line medication and who do not have excluding factors (see below).

   2. Early assessment of suspected cases for all patients newly presenting with suspected inflammatory arthritis.

   3. Psychosocial support, education and advice for all patients with inflammatory arthritis

Excluding factors for primary care based medical follow up as a substitute for secondary care

• Patients who prefer to continue with hospital based follow up.
• Patients with poorly controlled illness requiring frequent medication changes although some of the review these patients require might be carried out in primary care.
• Patients with complex disease e.g organ involvement.
• Clinical responsibility Practice nurse with specialist knowledge of rheumatology in liaison with designated GP with special interest or patient’s own GP, and in liaison with local rheumatology unit. Appointments 1. Referral . Self-referral or via another member of the primary care team. 2. Frequency . All patients would be reviewed annually or more frequently if appropriate. In addition they could easily be reviewed on request (cf the patient-initiated review service successfully developed by Kirwan et al (2003) in the Department of Academic Rheumatology at the BRI) 3. Timing . It is desirable that appointments at different times of day are available in order to minimize disruption to the rest of the patient’s life (ARMA).

4. Length. 30 minutes.

5. Home visits. could be undertaken for those who are housebound.

Content of review appointments

Medical monitoring

• History since last seen e.g any flares.

• Check for symptoms indicating possible involvement of other organs or disease modifying anti-rheumatic drug (DMARD) toxicity.
• Review results of blood tests for DMARD toxicity, disease activity and cardiovascular risk.
• Disease Activity Score 28 joint count (DAS 28) to measure current disease activity.
• Health Assessment Questionnaire score (HAQ) to assess level of function, level of pain, current disease activity and progression of disease.
• Screening and management of cardio-vascular risk (as for diabetics) including weight, BP, and lipids.
• Assess nutritional status and monitor for undesired weight loss.
• Assess skin condition (risk of ulcers).
• Liaise with GP to arrange investigations as required eg X-ray, scan.
• Psychosocial aspects and self-management
• Assess level of fatigue.
• Screen for depression using PHQ-9. People with inflammatory arthritis have higher than average rates of depression, which can be difficult to differentiate from effects of disease activity and resultant fatigue.
• Assess coping, support, social engagement.
• Assess impact on family and include close family members in education and discussion if appropriate/possible. Partners can experience considerable burden and may not fully understand the disease process and effects.Employment issues and benefit advice.
• Self-management education with individualized management plan (emphasis on collaboration and concordance rather than compliance).
• Provision of leaflets and information about where to access other services and resources, including self-management groups.
• Content of new patient assessment appointments
• Detailed history – onset, symptoms, effect on function, exacerbating factors.
• Current symptoms – pain, stiffness, fatigue, restriction of movement.
• DAS 28 score.
• Organize investigations as per protocol agreed with rheumatology unit.
• Arrange referral if appropriate and initiate 1st or 2nd line drug treatment in consultation with GP and/or rheumatologist.
• Referral

    * For early consultant review if deterioration or not tolerating DMARD or if new symptoms of concern.
    * To physio if muscle strengthening required or to increase range of movement or improve pain levels.
    * To OT if problems with activities of daily living.
    * To podiatrist if problems with feet.
    * To dietician if nutritional deficit.
    * To social services if social problems.
    * Liaise with GP if new symptoms or if deterioration in a joint indicates possible need for orthopaedic opinion.

Evaluation/audit

A questionnaire to assess patient satisfaction with the service after 1 year and any improvements that could be made.

Annual audit:

1. To check number of patients on disease register and number who have received review in last year

2. Number of patients who have been managed in primary care alone

3. Number of ‘flares’

4. Number of patients who have needed urgent review in secondary care

5. Other


References

Department of Health (2005b) Supporting people with long term conditions, an NHS and Social Care Model to support local innovation and integration [online]. London: Department of Health.

Arthritis and Musculoskeletal Alliance (2004) Standards of care for people with inflammatory arthritis.

T. Kennedy, C. McCabe, G. Struthers, H. Sinclair, K. Chakravaty, D. Bax, M. Shipley, R. Abernethy, T. Palferman , R. Hull (2004) BSR guidelines on standards of care for persons with rheumatoid arthritis. Rheumatology 44(4), 553-556.

Available http://rheumatology.oxfordjournals.org/cgi/content/full/44/4/553/#B05

Kirwan JR, Mitchell K, Hewlett S, Hehir M, Pollock J, Memel D, Bennett B (2003) Clinical and psychological outcome from a randomised controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years. Rheumatology 42, 422-426.