Mobilizing Care to Rural and Remote Locations Through the Wellness Wheel
With the wide expanse of the Saskatchewan prairies, much of our population lives in rural or remote locations. Access to a physician can, at times, be limited and transportation to larger urban centres is frequently required to attend specialist appointments or to receive treatments. Seeing the barriers many Saskatchewan residents are facing to access primary health care, Wellness Wheel Medical Clinic was created.
Wellness Wheel was originally brought to life by Dr. Stuart Skinner, an infectious diseases physician in Saskatchewan. He was noticing a high number of no-shows in his clinic in Saskatoon. In an effort to provide more equitable and accessible care, Dr. Skinner approached the surrounding communities to ask if they’d prefer to have him come to the community, eliminating the need to find transportation to the city. He continues to visit these communities, 10 years from their initial discussions. After moving to Regina in 2013, he then met with the Health Director from a Tribal Council in Southern Saskatchewan who advised that peers were interested in being able to access health care in their own community, rather than travelling to Regina. Soon after, some of the physicians and Elders, together with the Health Director and community members began their relationship in ceremony, supported by the Chief and Council of participating communities within the Tribal Council, and care began.
Susanne Nicolay, RN is the Clinical Coordinator and Nursing Lead at the Wellness Wheel Medical Clinic & Indigenous Community Research Network. With experience in public and sexual health, Susanne has been a part of the team for five years. This team, comprised of nurses, family physicians and specialists, work in partnership and collaboration with First Nations partners to improve equitable access to care, in a community led, community driven approach, grounded in culture and weighted in the local community’s health priorities. Wellness Wheel also works with a handful of rural non-Indigenous communities on an ongoing basis, as well as working with some non-traditional community partners in Regina, with a forecast of 100 clinics being held in these various partner locations in 2021. Susanne and her team are a perfect example of Registered Nurse Specialty Practices (RNSP) being used to optimize the scope of practice of RNs.
Susanne shared that, “Most of the care we do is remote. And it is a lot of things that you don't come out of nursing school being able to do. You know, any of the work around treatment for STIs, management of HIV and Hepatitis C, the Warfarin pieces, even drawing blood work, those are extra skills that are typically attained after you graduate from your four-year basic program. And I feel like they're pretty highly specialized.” Because of this, she has spent a great deal of time writing policies, procedures and orientation checklists that outline the additional specialized competencies required to be a nurse on this unique team and having them reviewed and approved by primary care physicians.
Originally, the care provided included drawing blood for HIV and Hepatitis C, providing counseling and some treatment for Sexually Transmitted Infections (STI). From there, it has evolved. With physicians accompanying the team once or twice a month, care has expanded to include phlebotomy and obtaining lab licenses that allow them to have the medical directives required for treating STIs such as chlamydia and gonorrhea. They’ve also introduced Naloxone kits to their practice, procuring them, providing them to patients and educating everyone to ensure they are familiar with their use.
Further to these expansions, with a large focus of the team being HIV and Hepatitis C testing and treatment, they’ve also expanded to providing HIV point-of-care testing that allows for nurses and providers who are legislated to be able to do the test, to provide it onsite and have a result within 60 seconds. In addition, they also provide dry blood spot testing, for any patients who may have poor venous access to ensure that any patient that requires a test, receives one. Susanne stressed that as nurses, the counseling and timing component of providing these tests is incredibly important, “There’s a few things that I think nurses have to assess and make judgements on. Making the decision to proceed with that point-of-care test, there’s the regimen around mental health and addiction safety because you are actually potentially getting life-changing information, in 60 seconds. Unless you’ve given an HIV result to somebody, it’s a really hard thing to do and I’ve done it lots and it’s still not easy.” Both tests require certain competencies by the practicing nurse, including reading and interpreting the test, counseling the patient regarding the result, getting a confirmatory test done and referring for potential treatment.
As the list of competencies and specialty practices continues to grow, a service Susanne is very excited that they have recently started to offer is specific pre and postnatal clinics where blood work and ultrasounds are provided. Many women who are living in rural or isolated on-reserve settings and don’t have easy access to primary health care are then coming into the city for delivery and immediately being flagged at the hospital for having no prenatal care. Susanne says they are working hard to change this and bridge the gaps of equitable access to care by offering more of these clinics with their partner communities and providing care throughout the pregnancy.
As one can imagine, remote care doesn’t come without its challenges. Many of the communities the Wellness Wheel team visits are within an hour’s distance from an urban centre, but are without lab services, primary health care or a pharmacy. Transportation is a major barrier for many of the patients Susanne and her team are seeing. Thus, a tremendous amount of collaboration with various health care providers, including pharmacies and physicians is required. These partnerships allow for test results and lab work to be reviewed with physicians prior to a new visit to a community and prescription drop-offs by delivering pharmacies.
The clinical team, with the support of their partner communities, has done a phenomenal job of expanding the care they provide, but Susanne noted that it is difficult to think of the communities they are not able to reach, “It’s insufficient when you think that there are over 70 First Nations communities, and these are four.” That being said, she is proud of the fact that of the communities they are able to serve, they are able to give them exactly what they want, based on the community’s needs and priorities. She shared that, “Anything we do is really what the community wants. It is a very community led, community driven approach. So, if their need is HIV, no problem. If their need is diabetes, no problem.”
She’s excited to see where their care may go in the future and the potential that RNSPs provide her team in terms of optimizing their scope of practice. She sees huge opportunities for RNs to renew medication for stable patients and optimizing scope in other settings such as STI clinics.
The work that started it all has truly come full circle as Susanne proudly shares that the original communities that Dr. Skinner visited, that had increased numbers of HIV and Hepatitis C, have received improved access to harm reduction programming, increased testing and have a large percentage of those diagnosed being virally supressed and actively engaged in .
As she reflected on how far the Wellness Wheel Medical Clinic has come in the last five years and the additional competencies that have been put into place to improve the care they provide, it’s obvious her heart is in it 100 percent as she said, “It’s hands down, the best work ever. I think if you asked any of us, it’s what we are, what we’re passionate about.”