We need a new model of care for chronic diseases in Manitoba

Opinion

For several decades now, if you have been a patient suspected to have a chronic disease such as rheumatoid arthritis, Crohn’s disease, ulcerative colitis, multiple sclerosis, etc, your typical route to get care is to meet with your primary care provider (family physician or nurse practitioner), if you have one, and be referred to a specialist physician.

Once diagnosed with one of these chronic diseases, ongoing care will typically be provided by your primary care provider and by the specialist.

The frequency of specialist visits will depend on the nature of your specific chronic disease and the style of practice of the specialist. If your chronic disease is uncomplicated, this paradigm can work well enough for patients.

If your disease becomes complicated or at least very active, you will need more immediate input from your primary care provider and/or specialist. This is one of the “pressure points” for patients and, if not appropriately managed, patients may have delayed care that will compromise their health, and/or spend inordinate amounts of time in emergency departments.

Once at an emergency department, they may be attended to by nurses or physicians who are not as familiar with many of the newer drugs being used to treat chronic diseases.

Chronic disease care has become so complex we can not expect generalists to have in-depth knowledge of the myriad drugs, targeted drug levels, drug interactions and drug complications that might emerge. The optimal management of a chronic disease that becomes complicated is by practitioners who have the requisite expertise.

In the inflammatory bowel disease clinic at the Health Sciences Centre, Winnipeg, nurse practitioner Constance Patmore has developed expertise in the management of inflammatory bowel disease (IBD). She is available by phone five days per week for all Manitobans with IBD.

They can call with any questions regarding their symptoms, their disease, or their drugs and if she does not know the answer she finds out from an IBD specialist gastroenterologist.

She may recognize that the caller requires urgent attention in an eergency department. She may recognize that a caller needs urgent mental health attention and she may help coordinate that with a clinical psychologist with a special interest in IBD, or with the psychiatry consult liaison service or with the caller’s primary care provider.

At present, there is no substantial wait time to get in touch with her. You do not need to be a patient at the Health Sciences Centre to access her. The alternative for the patient is to call Health Links, whose providers may not have the depth of knowledge to understand aspects of IBD management or the drugs being used to treat them.

Often, Health Links callers are directed to attend at urgent cares or emergency rooms. Another alternative for persons with IBD is to reach out to their primary care providers or their specialist gastroenterologists, who may not be readily accessible.

Many Manitobans do not have primary care providers, and many do have specialist care access. Manitobans living remotely from bigger centres have challenges of distance and so the ability to access care by phone would be a huge advantage.

We know that in the first two years of our nurse practitioner-run IBD “Health Links” phone clinic, Patmore has kept just about half of callers from going to emergency or urgent care. She has been an invaluable resource to callers and for some, has maintained telephone contact on a weekly basis for an extended period to be sure the caller got through the rough patch.

There are few primary care providers or specialists that can maintain that type of follow up schedule, even if needed.

The provincial nurse practitioner program has been doubled in size this year.

This is great news for developing alternative clinic models.

It is great news for the inflammatory bowel disease clinic at HSC because in time we will be needing a second nurse practitioner. There are approximately 12,000 Manitobans with IBD. Our clinic though cannot function with just a nurse practitioner.

Our nurse practitioner needs a clinic clerk to help triage and document callers and send out requisitions and forms.

She needs a registered nurse to help manage some of the IBD related problems, such as changing drug doses, renewing prescriptions, and following up important laboratory testing and communicating all this back to the patient.

For over two decades our clinic has accessed a registered dietitian and a clinical psychologist on an ad hoc basis. Nutrition and mental health are critical aspects of managing any chronic disease but especially diseases related to the gut and one’s diet, specifically. We have shown over the years that persons with IBD are more likely to have mental health disorders and those with mental health disorders fare worse in their IBD.

We need these health-care professionals to be incorporated into the IBD Clinic. We know from previously published work that providing mental health care proactively will reduce costs of IBD care. So having an IBD nurse practitioner has been an excellent start, but the province has yet to fully support this clinic model and so it remains understaffed and incomplete.

The province should be desperate for new models of care, especially for chronic diseases.

The model we have proposed has associated fixed costs. We also are proposing that it will be cost saving. It has already and will continue to reduce emergency department and urgent care utilization. Fixed costs and cost saving are key to government budgets.

However, governments should also care about the health of their community. This model greatly enhances the care and health security of persons with chronic diseases in Manitoba.

Dr. Charles Bernstein is the director of the University of Manitoba IBD Clinical and Research Centre and the Bingham Chair in Gastroenterology.