NCPS Urology Integrated Care E-referral & Nurse-Led Clinics

Abstract

Introduction: Urology referrals have increased 80% in recent years. With an aging population referrals are likely to increase further in future. There are a very limited number of experienced Urology Consultants available to deal with this increased workload. There are 34 fewer Consultants currently working in Ireland than the international standard of 1 per 1,000. There is also a diagnostic bottleneck around access to ultrasound and radiology services. There are large numbers of patients on waiting lists for urology outpatient services. Description of Changes: This project relates to the development of primary care referral pathways for benign urological symptoms and haematuria utilising an e-referral system. The project will also develop a secondary care nurse-led urology clinical procedure for benign urological symptoms. Aim & Theory: The aim is to deliver an increasing volume of urological care in the primary care setting, and improve Urology Outpatient Waiting times to meet the target of 18 months wait or less for all patients on the waitlist. The project will result in a more streamlined system for secondary care referrals and development of shared care with GPs, a reduction in Number of Outpatient visits per patient in Urology, greater cost efficiencies for hospitals & HSE and improved access to services for non-urgent patients. The study will include an analysis of resourcing necessary to deliver increased volumes of care in the primary care setting, as a pre requisite for conducting and scaling the study. Targeted Populations: This project is aimed at Urological Outpatients, Consultants, GPs, Registrars and Nurses. Other Stakeholders include hospital clerical staff, together with institutional stakeholders including the partner hospitals (Letterkenny General Hospital, University Hospital Waterford and Tallaght Hospital), The Irish College of General Practitioners (ICGP), The Royal College of Surgeons in Ireland (RCSI), The Irish Society of Urology (ISU), National Clinical Programme in Surgery (NCPS), National Cancer Care Programme (NCCP), Outpatient Services Process Improvement Programme (OSPIP). Timeline: Project inception and design began in August 2016. The e-referral form was prepared in December 2016, is for piloting for January 2017. The nurse-led clinics will start in January 2017 with review in May 2017. Highlights: Predicted outcomes include an agreed and universal GP e-referral form for Urology, advice and guidance agreed by Urology Specialty Consultants and GPs, in order to enable GPs to treat patients in primary care, creation of rapid access haematuria clinics and haematuria referral pathway, decreased OPD waiting times in Urology, creating cohorts of patients to allow distribution amongst primary care, model 3 and model 4 hospitals, and a clearer picture of referral to be dealt with for 1st appointment. Detail regarding necessary levels of resourcing for delivery of these services in the primary care setting will also be elaborated as part of the study. An increase in secondary-care nurse-led clinics under urological specialty consultant supervision. Sustainability & transferability: In order to facilitate sustainability and transferability an SOP will be developed to ensure consistent application is possible across the country. The e-referral form can be used as a template for any other specialities. It will require to be approved by GPIT, a working group comprising the ICGP, The HSE-OSPIP and the OFCIO. Conclusion: A pilot secondary care nurse led clinic run in Letterkenny has been able to reduce outpatient attendances, using a “Hub and Spoke” model where urgent and elective routine patients are treated at the HUB hospital – University Hospital Galway. Discussion: Following planned implementation in Tallaght and University Hospital Waterford, this outpatient integrated care initiative is anticipated to avoid long wait times and provide timely access and treatment for Urological patients across three hospital groups Saolta, South/South West Hospital Group (SSWHG) and the Dublin Midland Hospital Group (DML) in the initial phase, including transfer of care into primary care, together with a more efficient process at OPDs in the secondary care setting. Lessons learned: Integrated care across Primary and Secondary Care can work by working collaboratively with GPs, HSE Outpatient Services and Urology Specialties in Acute Hospitals.