Download The Right Provider at the Right Time

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The Right Provider at the Right Time:
Maximizing RNs’ Scope of Practice to Increase Access for
Marginalized Populations
Sheena Howard, RN, BScN, Primary Care Nurse
Dr. V. Lokanathan, MDCM, CCFP, Family Physician
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Conflict of Interest
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None to declare
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Passion
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Dedication

Advocate
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Social Media
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#primarycarenurse
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#primarycarenurses
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#PatientsFirst
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@SheenaLGHoward
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@VanitaLok
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@RNAO
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@RPNAO
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@RainbowHealthOn
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Patient Population Focus
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Trans and Gender Diverse (TGD)
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Historical and current social marginalization
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Historical and current disparities regarding their ability to
access equitable health care services
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Poor health outcomes based on marginalization and health
inequity
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Ideal patient population to outline how to increase access to
primary care services by maximizing RN scope
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Presentation Outline
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Terms

Situation for TGD people regarding access to health care
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Background regarding health disparities for TGD people
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Assessment of TGD population’s needs
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Response of Team
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Outcomes of Increased RN Scope for Patient Population
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Conclusion
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Q and A
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Terms
Gender Dysphoria
Transgender
Gender Diverse
Cisgender
Non-Binary
MTF
FTM
Gender Affirming Surgery
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Gender Dysphoria
Distress associated with gender identity not
matching assigned gender
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Trans/Transgender
Gender identity doesn’t match gender
assigned at birth
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Gender Diverse
A person whose gender identity does not
align with binary gender categories such as
“man/ woman”, “boy/girl”
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Cisgender
Gender identity matches gender assigned at
birth
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Non-Binary
Umbrella term for anyone who does not identify
with static, binary gender identities
Includes persons who may identify as having an
intermediary gender (e g genderqueer), as
being multiple genders, as having a constantly
shifting gender, or as not having a gender
altogether
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MTF
An old term to describe trans women
It has fallen out of favour as it implies that trans
women are something categorically different
or apart from being “women”
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FTM
An old term to describe trans men
It has fallen out of favour as it implies that trans
men are something categorically different or
apart from being “men”;
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Gender Affirming Surgery
Previously known as sex reassignment surgery
Can refer to any number of surgeries that a
trans person may undertake in order to better
align their sex with their gender identity
+ Situation for TGD people in Central
Ontario regarding access to health
care
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Limited access to primary care providers who were willing to
assess and treat gender dysphoria or provide referrals for
assessment, treatment or surgery
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Two urban Gender Clinics were the only option for TDG people
wishing to transition with medical support, each with wait times
of up to two years. One clinic was only accessible with a
Toronto address.
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Approaches to assessment - Pathologization vs. Gatekeeping vs.
Informed Consent
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Health care providers belief that assessment and treatment “out
of their scope”
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Historical mistreatment of TGD people by health care
professionals
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Background Regarding health
disparities for TDG people
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Increased risks of suicidal ideation, self harm and suicide
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Increased mental health co-morbidities
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Increased risk of Sexually Transmitted Infections
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Increased risk of sexual and physical violence
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Despite level of education, worse socio-economic status
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Risk of adverse effects due to self medication
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Biggest risk to health is related to violence and self harm
from social stigma and discrimination, not to medication side
effects
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Assessment of TGD Populations
Needs in Central Ontario
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Unofficial wait time at CAMH Gender Identity Clinic in Toronto was four
years and this is the only referral centre for patients outside “the 416 area
code”
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Transpulse Research, Being Safe and Being Me Survey, EGALE National
Survery on Homophobia, Bi-Phobia and Transphobia in Canadian Schools
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Greatest risk of self harm in the interval between self realization (coming
out) and access to competent medical care
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Access to assessment and hormone treatment was lacking in Central
Ontario’s small cities and rural areas
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Began with one patient, referrals kept coming, some from very curious
places!
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MD’s ability to deliver accessible care was becoming untenable without
support
Every Class in Every School
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First National Survey on Homophobia, Biphobia & Transphobia
in Canadian Schools
74
80
70
60
49
50
37
40
30
23
20
10
0
Teacher
Verbal
transphobia harassment
Physical
harm
Sexual
harassment
Guess which are the two school spaces experienced as most unsafe by LGBTQ students?
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Being Safe, Being Me
The Trans Youth Health Survey
Reported Rates of Harm
80
70
60
50
40
30
20
10
0
73
36
66
33
Reported Rates of Help
70
60
50
40
30
20
10
0
66
50
30
15
Transpulse Research Reports…




71% transOntarians
report ever having
considered suicide
50% considered suicide
because of being trans
43% attempted suicide
60% reported depression
at some time in their life
Cis
Trans*
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Response from Team
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Increased requests for assessment and hormonal treatment was starting to
become overwhelming
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RN already working to full scope in other areas of primary care practice, and
was working with strong interprofessional collaboration and support
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Willingness + social justice
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Reviewed Sherbourne Guidelines and realized that many Guidelines fit
perfectly with the Phase Two Role Description of the Primary Care Nurse
outlined in the RNAO Document - “Primary Solutions for Primary Care”
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Rainbow Health Ontario Trans Cultural Competence and Clinical Training for
RN and On-the-job mentorship with MD
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GP/RN team asked to support Trillium Grant for community driven group
support group – Gender Journeys
Sherbourne Guidelines
and Protocols for Hormone
Therapy and Primary
+ Health Care for Trans
Clients
Five Steps for Assessment Period
Psychosocial Readiness
Trans Care Assessment Period Checklists
Hormone Monitoring Summaries for
Collaborative MD and Nursing Team
RNAO Primary Solutions
for Primary Care
+ Maximizing and Expanding the Role of the
Primary Care Nurse in Ontario
Primary Care Nurse Task Force Report
RNAO Primary Care Nurse Task
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Force Report
Phase Two Role Description Review
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Case Study
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35 yr old MTF from a rural community. Married to a cisgender woman
and has one child. Full time job in a traditionally male dominated
environment.
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Has known since childhood that she was a female, and struggled with
gender dysphoria related to her stereotypical physical male traits, and
dysphoria was complicated by anxiety and depression. She was not
being treated with medications for her anxiety or depression.
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Family history of high blood pressure and mental health issues. Her
wife was tentatively supportive, but not interested in being married to a
woman. She was accessing counseling for support in home community
with a trans-friendly social worker, however, family physician declared
assessment and treatment as “out of his scope”.
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She self referred for assessment and treatment of possible gender
dysphoria.
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Phase Two Role Descriptions
Registered Nurse – Domains of Practice
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Assessment *
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Management/Administration
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Program Management
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Planning
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Care Co-ordination* (New
Domain)
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Education
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Advocacy *
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Collaboration*
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Knowledge
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Professional Commitment
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Documentation
Quality Improvement
Treatment *
Patient Self-Management *
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Provide comprehensive physical and
psychosocial patient assessment
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Health Screening
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Interpreting Assessments – “huddles”
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Ordering diagnostic tests *
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Identifies and communicates a
diagnosis to initiate prompt treatment
for health conditions within the RN
competencies, knowledge and skill *
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CASE STUDY – the assessment period
was over 3 visits, as patient identified
ambivalence to transitioning
Assessment
Private office
Dedicated time
EMR Messaging
Templates
Diagnostic Tests
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Program
Management
Rainbow Health Ontario Advocacy
Centre for Addiction and Mental
Health
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Gender Journeys Advisory Committee
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Gender Journeys evaluation
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Care Co-ordination
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Provides primary care patients with a
seamless experience through the
health system through timely access
and working closely with all health
professionals
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Assists patients with navigating the
health system and accessing the right
care, at the right time, by the right
health professional
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Interprets findings and evidence to
develop a comprehensive care plan in
collaboration with interprofessional
team with a focus on preventing
unnecessary hospitalization
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CASE STUDY
Private office
Morning and Afternoon Huddles
EMR Messaging
CAMH Referrals by RN
Referrals to Mental Health Clinicians
by RN
Consult Letters to GPs and NP from
RN
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Documentation
and
Quality Improvement
(QI)
EMR Utilization
EMR Messaging
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Maintains thorough and comprehensive
documentation in alignment with
standards and the needs of the
interprofessional team
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Embraces electronic documentation
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Evidence-based champion, using
evidence-based knowledge and best
practices to guide clinical and work
environment practices (streamlining
assessment process)
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Participates and leads QI initiatives by
collecting, interpreting and reporting
health data to support continuous QI
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CASE STUDY
EMR Templates and Forms
Sherbourne Guidelines and Protocols
imbedded in EMR
Data to support Trillium Grant
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Remains accessible via telephone and
in person to provide health counseling
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Manages immunization programs
including assessing records, identifying
outstanding vaccinations required, and
administering vaccines when
appropriate
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Provides medication management
expertise, including the initiation and
renewal of prescribed medication *
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Provides clinical services with a higher
degree of complexity *testosterone and
delegation of function
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CASE STUDY
Treatment
Public Health Immunizations
Telephone
EMR Messaging
Disease Prevention
CNO Delegation of Function
Guidelines
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Patient
Self-Management
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Leads upstream health promotion
activities, rooted in social determinants
of health, that also emphasize
accessibility , early
detection/intervention, lifestyle
counseling, and disease prevention
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Supports patients at identifying and
utilizing community resources
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Develops, monitors and refines
individualized care plans in
collaboration with interprofessional
team
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Involves the patient in the forefront of
all care decisions
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Works as a systems navigator to ensure
appropriate referrals and connections
are made
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CASE STUDY
Informed Consent
Smoking cessation counseling
STI prevention and Diagnostic tests
Gender Journeys
CAMH referrals
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Management/Adminis
tration
and
Planning
FHT TransHealth Initiative
RHO Advocacy for SRS Referral
Process Changes
Cultural Competency
Gender Journeys Advisory
Committee
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Acts as resources to the clinical
practice team by providing knowledge
and expertise within the RN Role
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Support staff development
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Leads the review, implementation, and
planning of projects that support
effective patient care
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Provides a nursing perspective on
planning activities within organizations
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Conducts patient and community needs
assessments
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Evaluates programs and practices, and
revises as necessary
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CASE STUDY
Positive Space Training in FHO
Environmental Scanning to
Benchmark Best-Practices
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Education
RHO
Peterborough Aids Resource Network
Rainbow Youth
Gender Journeys
Positive Space Training
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Assess education needs amongst
patients and within community
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Engages in one-on-one patient
education regarding: health promotion,
disease management and prevention,
mental health, lifestyle, medication
management, community supports and
social considerations
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Supports staff education
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CASE STUDY
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Advocacy
and
Collaboration
RHO Advocacy for SRS Referral
Process Changes
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Advocacy
and
Collaboration
LGBTQ TaskForce
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Advocates for the patient as a care co-ordinator
*even within your team!
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Advances the principles of primary health care
within communities
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Advocates for health communities through
social justice and equality
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Advocates for an environment that supports the
patients’ and maximizes their participation and
control in meeting their health goals
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Participates in community groups to address
identified needs
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Collaborates, as an active member of the
interprofessional team, with a number of health
professionals to support quality patient care
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Consults with a more experienced team
member of the interprofessional team if an
issue arises outside of RNs scope or if unclear
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Fosters strong linkages with public health
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CASE STUDY
FHT TransHealth Initiative
Gender Journey LHIN Funding
Informed Consent
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Knowledge
and
Professional
Commitment
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Holds expert knowledge and
proficiency within the RN role
regarding current evidence-based
practices, leveraging best-practice
guidelines, effective delivery of
primary health care and nursing, social
determinants of health, cultural
competence
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Mentors students
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Maintains a commitment to life long
learning, self reflection and
professional development
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Disseminates knowledge to peers and
community through publications and
presentations
Sherbourne Guidelines and Protocols
RHO Conference
Maximizing RN Scope
Social Media
RN Student Preceptor
Provincial, National & International
Conference and Workshop
Presentations
LGBTQ RNAO Best Practice
Guidelines
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Outcomes of Increased RN Scope
of Practice for Patient Population
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Increased patient capacity and
volume to provide timely
access to assessment and
treatment of gender dysphoria
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Increased community support
links for patient population
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Increased community capacity
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Improved patient outcomes,
increased self efficacy
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Increased cultural competency
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Decreased unnecessary hospital
visits
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Increase role satisfaction
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Increased spread of
knowledge and competency
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Increased point-of-care
leadership
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Decrease in suicidal ideation for
an at risk population
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Increased availability of surgical
referrals
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Patients’ Voices
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“Having Sheena as my RN has changed my life in so many
positive ways. She has guided and cared for me through the
most important journey of my life, and continues to offer me
the highest quality of professional medical care I have ever
experienced. The fact that I have had the opportunity to visit
Sheena and have her oversee this journey has in many ways
saved my life-both emotionally and physically. I am
extremely fortunate to be the patient of an RN - and a
fantastic one at that! Having prescriptions written by Sheena's
consulting physician has never, in any way, been a hindrance
to me and my medication and treatment needs have always
been met more than promptly through this process of care. I
feel privileged to have access to Sheena's care as an RN and
would strongly advocate for more individuals to have access
to such valuable medical professionals. "
M. - 27 yr old. Transman from a small city in Central Ontario
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Patients’ Voices
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“Having access to an RN has majorly impacted my access to
care because it fast-forwarded my accessibility to HRT and
my impending surgical referrals. I am so very grateful to my
nurse, and for the confidence and happiness she bestowed
on me. It doesn’t really bother me that Sheena can’t write my
prescriptions, and I wish that more nurses could prescribe
medication. I trust Sheena to support me to make decisions
for myself about the best route to go and what the available
prescriptions are. “
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P. - 21 yr old Transman from a large city in Eastern Ontario
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Provider’s Voices
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“Increased access is not just about more timely availability of care.
Embracing the idea of “the right provider at the right time” also
means knowing there are some things nurses do better than I do.
For my trans patients it means that sometimes I am able to “see”
them more fully and be a better doctor to them when I see them
through a nurse’s eyes. “
Dr. V. Lokanathan, MDCM, CCFP
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“Having Sheena in a full scope RN capacity in the community is about
putting patients first. That’s what nurses do every day in our
communities. The full potential of nursing capacity is an untapped
resource if we want to improve the quality of patient care. We need to
recognize that the current nursing scope does not reflect the true
capacity of nurses as knowledge professionals. The question of nursing
scope is to capture the essential work that is already taking place to
support patients at the point of care and expand upon their knowledge
capital to build healthier communities.”
Lisa Ducharme, MScN, RN(EC)
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CASE STUDY
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“Having access to an RN for my transition has been an
amazing experience. I will say that I did not have this kind of
health care before, and not having Sheena in my life would
mean that I wouldn’t be alive today. My RN has been one of
the most caring and helpful people in my whole transition.
She has provided me access to assessments and treatments
without having to wait for 4+ years for CAMH. It has also
been more than the medical aspect. When I go to see her I
feel like part of the family. It is a very safe and comfortable
environment. I am able to talk with her about anything. This
is something I’ve never had with a DR. She has even
advocated for help for me to have my surgical assessment
expedited. I am eternally grateful for the wonderful life
changing health care experience Sheena has provided me.
Without this kind of access to care, I don’t know what
would’ve happened to me.”
R. a 35 yr old Transwoman
from a rural community in Central Ontario
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CASE
STUDY
Update
All pictures used with express written and
verbal consent of parties pictured
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Conclusion
Contact: [email protected]
Thank you to RNAO for supplying the hardcopies of Primary Solutions for
Primary Care
Maximizing RN Scope is possible in a traditional health care setting, and we can
be the agents of change to support marginalized populations to have timely
access to primary care.
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Are you still engaged?
Questions?