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Understanding the Clinical Context: A Conversation with Dr Mike Scott
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Из курса от партнера Duke University
Healthcare Innovation and Entrepreneurship
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Prioritizing Needs
What is the full cycle of care? How do you prioritize needs? How do you specify needs? How do you prepare a Need Statement?
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Marilyn M. Lombardi, Ph.D.Associate Clinical Professor
School of Nursing
Bob Barnes, PhDInstructor
Biomedical Engineering
[SOUND] This is Duke University.
>> I have the pleasure to talk today to Dr.
William Micheal Scott, who teaches at the Duke University School of Nursing.
For over two decades, Mike has been a family nurse practitioner.
With most of the years spent as a primary care provider.
At a nurse practitioner practice in Rural South Carolina.
Mike was originally brought to Duke University School of Nursing to be
Director of Clinics.
Responsible for trying to implement a health care delivery model
run by the nursing school to showcase the efforts of advance practice nurses.
With the completion of his Doctor of Nursing practice degree,
Mike transitioned into the faculty ranks where he teaches primarily in
the graduate family nurse practice track.
Now, he's been recognized for
his national leadership in the Commission on Collegiate Nursing Education.
Where he is advocated for an expanded role for nurse practitioners.
And help to set the accreditation standards for
the relatively new Doctor of Nursing practice degree.
For his continued presence and rural health care outreach,
his vision of primary care redesign and as mentorship to nurse practitioner students.
Mike was recognized as North Carolina's Nurse Practitioner of the year in 2010.
So Mike, could you tell us a little bit about what it is to
be an advanced nurse practitioner?
>> Thank you Marilyn, I'm delighted to be invited to talk with you this afternoon.
Yes, I think it's important for everyone to get on the same page,
to speak of in terms of what exactly is an advanced practice nurse, or APN.
As it's known in some countries or an APRN,
or Advanced Practice Registered Nurse in others.
>> Mm-hm.
>> And basically is an advanced practice nurse are those nurses who buy
merit of their advance graduate education, either at the Masters or the Doctor level.
And their advance clinical training then able them to perform
diagnostic assessments.
And other levels of medical decision making that previously
well it had been only to certain types of healthcare providers, mainly physicians.
So, the thing about advanced practice nursing as
it's envisioned within the United States,
is that there are actually four distinct areas of advanced practice in nursing.
One of those is the nurse practitioner, of which I am one.
The other is the certified nursing midwife,
which most people are familiar with.
There is nurse anesthesia, these are the nurses where by way of their advanced
education and call of the training actually put you to sleep and
bring you back, after the procedure is over.
And then, there's the clinical nurse specialist who traditionally has
been in hospital based units dealing with patient care and
other staff related needs for that to keep care facility.
So, as a nurse practitioner,
one of the question is what is your training consist of?
Well, it's interesting.
We did not just evolve yesterday.
Advance practice nursing, in terms of the nurse practitioner,
as a matter of fact, has been around for almost 50 years.
And it came out of that interesting context in the 1960s,
where everything seemed to be changing.
You had changes in the culture.
You had changes in the societal level.
You had in the United States under President Johnson's War on Poverty.
You had a big do something for others sort of notion.
>> Hm-hm. >> It kind of translated down into certain
professions.
Well, during that time period, we knew there were many areas within
the United States that did not have, there were not adequate facilities or
providers to take care of Individuals living in those areas.
Primarily the rural areas but then United States and also our inner city areas.
Where other health care providers chose not to go for whatever reason.
Well as a result of this and all the changes that were taking place.
We had this idea that was brought forward by a couple
in Colorado actually, at the University of Colorado, Dr.
Henry Ford and Dr. Loretta, excuse me, Dr. Loretta Ford and Dr. Henry Silver.
Dr. Ford is actually, was a community nurse in the area of pediatrics as well.
Dr. Silver is a pediatrician, and
they got together and they had this idea of taking a nurse.
And educating,
actually I'm going to say her because most nurses at that time were her.
To where she would be able to distinguish normal from abnormal.
>> Mm-hm.
>> And with that knowledge in mind,
building upon her already ingrained nursing skills.
That particular provider would then be with a pediatrician,
by which she would be able to take children, mostly at the well child status.
And do the routine health maintenance,
freeing the pediatrician up to do more of the complex medical sorts of cases.
And that relationship, that collaboration actually kicked off really well and from
that simple area of pediatrics, mostly in the wellness care spectrum along that.
We grew to what we are now as almost,
as heading toward doctoraly prepared health professionals in our own right.
And the evolution that's taken place and it's actually quite remarkable to think
that it's taken place only within the last 50 years.
And there were a lot of course barriers that had to
be surmounted on whether nurses should be doing these sorts of things.
>> Mm-hm. >> Who is actually responsible for
the patient?
What is the role now between a nurse and physician?
In a way that beforehand was pretty much regimented.
So, there was a lot of things that were challenged at the time.
But we've seen this new type of health care profession now join the ranks.
And surprisingly what we're able to do within that realm, so.
>> Now bring it to you, yourself personally and your practice.
>> Okay.
>> And we've seen an evolution when I introduced you there was sort of
an evolution of your practice to the point where you got a DNP.
>> Yeah.
>> So, tell us a little bit about what it feels like to be a nurse practitioner
today for you.
>> Wow, 20 years ago, we thought we were living at a time
where we were just, the challenges were going to be there, but
we thought everything was going to kind of plateau out after a while.
And now we're in this era of healthcare reform that we don't know really
what's going to happen.
We do know that based upon the Affordable Healthcare Act,
as of January 1 of this year.
We're going to add 32 million Americans to the insured rolls.
So, if we do the math, we have to figure out well who is going to
take care of all these people at the primary care level?
Our colleagues, or family practice physicians are only so many, and
those numbers have been dwindling over the years.
In fact, the American Association of Colleges at Madison are predicting,
that by the middle of the next decade.
That then maybe a doth of 130,000 physicians.
So, this is at a time they were adding people to the role.
So, what can we do, and being proactive and
thinking ahead about of adding to the provider roles as well?
>> Mm-hm.
>> It has now been noted that nurse practitioners, in study after study,
have been shown to be as very cost-effective, safe.
And fully capable of delivering the care that is needed
to these sections of society.
So, in my own case, because I've gone the full route from a traditional
nurse practitioner model, actually at a health department setting.
Into a fully independent nurse practitioner practice.
And now, post my doctoral degree >> Now with my,
and my other added responsibilities with the school of nursing,
is my contractual relationship with a major health insurance company.
Which has formulated as a house calls division.
By which we try to pinpoint early healthcare problems
within the chronic care population.
And by direct intervention, maybe we can ward off some of those negative
ramifications of those sorts of problems.
Before these people end up in emergency rooms or in hospitals.
And so, basically we're taking about specialized medicare advantage plans.
Which by, and as a benefit to these
health insurance members get the benefit of having me come in the home once a year.
Well, I do a complete assessment we're looking at a cognitive assessment
of the individual.
A full physical assessment, a full psychosocial assessment,
a full resource assessment, I'm looking at the environment on terms of safety issues.
>> Mm-hm.
>> I'm reviewing medications, we're talking about an aging population.
So, we're talking about polypharmacy or many different types of medicines.
And looking at the possibility of drug-to-drug interactions.
And again, trying to pinpoint early problems, by which I can then notify
the persons, excuse me, the member's primary health care provider.
Be that another nurse practitioner, a physician assistant, or a physician of
the things that I'm finding out in the home, which they may not be aware of.
>> Well, you know this is fascinating for
all of us in this course I think because of the way our class is focused.
I'm thinking in the media there's a lot of coverage of late.
When it comes to nurse practitioners in the scope of practice related to
diagnostic issues.
Particularly because of the rise of this new retail clinic model.
So, 80% of those are staffed by nurse practitioners.
>> Correct, mm-hm.
And I'm wondering whether you see a future for health care systems
actually partnering with pharmacies or that retail
pharmacies in this kind of way or is this going to be an independent operation?
>> Well that's interesting that you bring that up.
We've been looking over the last decade of the rise of the retail health
clinic- >> Mm-hm.
>> Movement and see where it would be going.
Now these are CVSs mini-clinic of the world.
>> CVS being a pharmacy in the United States.
>> Correct. >> Yeah.
>> And Walgreens of another world- >> Right.
>> We also have target has it's own retail health market niche now.
>> Mm-hm. >> As well as others.
But getting that first, before we go there.
>> Yeah. >> Is the role in nurse practitioner and
doing those things.
>> Right. >> Right.
>> Right? >> Right.
>> And those skills sets what makes them as much as apart of that advance clinical
decision training that they have is in the ability to order diagnostic and
interpret diagnostic tests.
Such as labs such as basic radiological procedures.
It also includes the prescribing of medications obviously,
putting together a treatment plan.
>> Mm-hm.
>> Now in the retail health market,
is pretty interesting because in the west here, we live in a fast paced society.
And convenience is like to be underlined.
And we all have an examples of a mother or
father who a very busy lives and it come home and a child has a sore throat.
And it's friday at 6 o'clock in the evening where after you come over busy but
you know you don't want to take the child to an emergency room.
because I would not be in proper place but
you then again you don't want to wait until saturday morning.
Because what may be open then,
your physician on your primary care provider may be close.
So here, the genius behind the retail whole package is, is just said well,
we make it convenient.
There's no appointments, it's 12 hours.
It's [CROSSTALK]- >> [LAUGH] almost drive thru.
>> It's almost.
It is staff by license health care professionals.
>> Mm-hm. >> Who know what they're doing.
>> Mm-hm.
>> They have pretty straight forward protocols by which things that
they see and things that they don't see.
Which has actually made it more accepted over time.
They have a really list, and actually it's a-
>> What do they defer people to other?
>> Either to an urgent care setting or in some cases to an emergency room.
But it's pretty straight forward what they can see, and what they can't see.
They're pretty limited by what they can actually order, in terms of lab testing.
Because they are in a pharmacy location, versus a primary care practice or
a cliche facility.
>> Sure.
>> But they do a lot, with what they are capable of doing of.
>> Mm-hm. >> And I think it's not, many people were,
many analyst in the industry were thinking it's going to be a fly by night thing and
it's going to die out.
But I think it's only gotten even better over time as people got into this.
From basic things like bladder infections, to strep throat, to a rash,
to a cold, to flu.
And in between, if your child needs a sports physical to play high
school- >> Right.
>> Sports, there you go.
There's another, I don't have to make an appointment.
The forms are already there, they're in the computer database.
The professional fills them out, does the exam, and off you go.
And the fees are up front, kind of like a menu.
You know exactly what you're paying for.
>> Uh-huh.
>> And people generally are very satisfied with that type of care.
Now it doesn't fit and a lot of different ways, with the way that epidemiology
is growing here in the United States which is basically chronic disease based.
>> Right. >> And as we mentioned
80% which talking again an aging population in
the multitude of chronic diseases that we face as we age.
So, there are some markets within the retail health change
are looking at have the deliver chronic care.
>> Mm-hm.
>> Is not up and running yet, the thing to remember about retail health is
the fact they are, they don't want to take over the person's health care.
>> They're not the medical home I think that's a important part.
>> Correct,
which is the end of the patients center medical home is a big thing right now.
>> Right. >> And as part of this focus thing that
you were talking about where we get focused and having a home.
Where by we deposit or reposit most of our healthcare information and
where we go when we get ill.
But not only when we get ill but to get our health maintenance needs met, so
hopefully we don't become ill.
But now that kind of, so the retail health market kind of works in a way
whereby the patients in a medical home can't be there 24 hours a day.
>> Mm-hm. >> But to fill this niche,
the retail health market changes now have come in, so.
>> I want to put in the context for this course, just a little bit by saying that,
see how the advanced nurse practitioner is an ideal
partner for redesigning processes that aren't effective,
that have inadequacies, that have limitations right now current practice.
That I think the advanced nurse practitioner understands,
work around culture.
Where something isn't working right this moment, and
they just on their own initiative, make a difference.
But then how did they scaled that difference up?
And so, I'm thinking there are nurse practitioners out there and
I hope they are in this class as well.
Who are thinking, I have a better idea for doing that.
Who do I talk to?
How do I advocate for my position in the structure that we have now?
Have you ever encountered a time when you said I really can-
>> Yes, yes.
>> Change this?
>> Actually, in the primary care practice that I was
affiliated with in South Carolina, which is very much a nursing model system.
When we had issues, logistical issues.
If we were looking at even scope of practice issues, within the the states
the best way to do is to develop contacts, form collegial relationships with
people within state Boards of Nursing- >> Okay.
>> Within United States.
These are the people actually regulate as I related to you earlier.
On the global side of line the International Council of Nurses or
ICN in Geneva.
>> Mm-hm.
>> They do have an advance practice coalition and
this can use easily access on the web.
And they give a lot of different interviews,
they give some interesting studies have been done on the knows
practitioner in terms of their cause effectiveness,
their productivity worldwide, when is to trend going worldwide?
Where on those practitioners really being utilized in a very
efficient way worldwide.
>> Mm-hm.
And even that, even establishing those source of contacts for those nurses who
are really forward thinking can get the ball rolling along those lines.
>> And I think also in the context of our course,
once again it's those nurse practitioners who are forward thinking enough
to go beyond what is typically known as inter-professional contact.
Which is others within the healthcare profession, but move beyond that and
think I'd like to discuss something with a business developer.
>> Absolutely.
>> Or with an engineer Because I can see this idea needs
that kind of input in order to take it to the next step.
>> Yeah and I can think of things along those lines.
As particularly with people connected to business.
Particularly those individuals who may be in the insurance industry.
I mean that's- >> Right.
>> That's a good relationship to have there.
Somebody within the industry.
Looking at what are the trends are.
For instance in our country about health insurance companies reimbursing nurse
practitioners for services rendered.
>> Mm-hm. >> And how and
what are those schedules like, and how are those formulas made?
And what is the thought processes behind that from a business perspective.
On the engineering side, particularly,
as we got into the world of telemedicine, right?
>> Mm-hm.
>> Where utilizing technology in these rural areas to deliver care.
>> That's right. >> With link ups to torchuary centers,
like here what we have at Duke.
And using, looking at those logical processes,
those ways that are interact at that level.
Again, with the goal being to promote health in those areas.
I think, actually I think it's a fascinating thing as we go forward and
a great place for nurse practitioners to be.
>> That's right.
>> Yeah. >> I think there are many great places for
nurse practitioners to be.
Thank you so much.
>> You're welcome, and the other thing is for
individuals even outside of the boundaries of the United States.
Look at our nurse practitioner organizations.
>> Mm-hm.
>> Because they do a great job in terms of the PR campaign.
>> Okay. >> I've helped to get the board of who and
what we are.
And the number one that comes to mind to me is the American Association of
Nurse Practitioners.
>> Right.
>> And so, people should remember that AANP as a big one that they can look.
Lots of resources there, they have a long standing history of
helping nurse practitioners, particularly nurse practitioners that have an idea.
And this idea is what is really interesting
because once the idea's planted, I mean, who knows where that can go?
>> Thank you so much.
>> You're quite welcome, thank you for inviting me.
>> Okay, and thank you for listening and we'll see you next time, bye for now.
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