Popular nurse-run clinic fights to survive
Anita Joly bared a thin arm for a cuff that would measure her blood pressure — and then made a strong-arm fist. She laughed. Not bad for a 90-year-old, she confided: “You know, I have a sister who’s much rounder but I’ve always been small.”
Sitting on an examination table in Room 3, Joly chatted to her family doctor about all manner of issues affecting her health, from her poor appetite to her sleeping arrangements for a swollen leg.
“Blood pressure is good — for a 90-year-old,” Dr. Karen Lee told her patient. “Looks like you’ll live beyond 100.”
“What can I say? My doctor is very good,” Joly quipped.
The doctor’s services, however, are only a fraction of the amenities at Centre médical talin, a nurse-owned, nurse-run clinic in Candiac that operates like a club.
It is softly lit, with potted ceiling lights, pale blue walls and fresh coffee brewing in a waiting area with artwork and comfortable sofa chairs. Medical records are electronic, accessible on a secure website anywhere in the world with an internet connection.
This winter, Joly became one of 14,000 clients at TaLin, a centre with a patient-centred philosophy: patrons are to be equal partners in recovery from illness and the promotion of their own health.
For an annual fee of $175, people who sign a “patient partnership” contract get unlimited access to a nurse — via telephone, email or in person — often on the same day, all year round, from 8 a.m. to 9 p.m. weekdays, until 6:30 p.m. Saturday, and 5 p.m. Sunday, except on St-Jean-Baptiste, the only day the clinic is closed. It targets long-term health prevention and chronic-care maintenance, but also takes walk-ins, so no contract is required for those needing, for example, a prescription renewal.
TaLin has two regular doctors on staff during the week: a family physician and a pediatrician. If a patient’s problem is beyond the scope of a nurse or family doctor, the clinic has a dozen hospital medical internists and specialists who moonlight at the clinic on weekends.
The clinic is the brainchild of nurse Linda Jurick, who saw a wide gap on the South Shore in terms of patient services. Jurick initially wanted to open a traditional family doctor clinic, known as a GMF (groupe de médecine de famille), five years ago. But after renting space above a pharmacy in downtown Candiac, her efforts were thwarted by government limits on the number of permits the province accords to physicians in an area.
Without the ability to recruit family doctors, Jurick turned to another formula, the patient-partnership, a strategy developed by the Université de Montréal faculty of medicine and research institute, to engage and integrate patients in care. It also borrows from a model pioneered by McGill University nurses, the patient-centred care.
It’s a humanistic, holistic approach, Jurick said. And every step is nurse-coordinated “to get the desired outcomes for patients,” she said. The clinic deals with a range of complex medical conditions, from diabetes and cancer to kidney and cardiac care. Key is the patient’s collaboration to reach health goals, whether to improve fitness levels or heart function.
But it was tough with the first 100 patients; no one was used to the concept of a nurse being in charge, Jurick said. “Getting people to trust a nurse, there was a lot of teaching involved,” she said. “But now patient engagement is well established in the community.”
Aided by one of the clinic’s 10 nurses, patients identify goals and design plans at their own pace — whether it’s to eat more greens or stop smoking. Of 14,000 patients, 3,000 have signed up for partnerships. The rest attend the clinic on a walk-in basis. Drop-in patients pay a consultation fee of $60 to see a nurse and they come from all over the Montérégie.
Yet TaLin — the only clinic of its kind in Quebec — is struggling to survive.
Operating in a similar vein is Sabsa, a nurse clinic in Quebec City. But unlike TaLin, it’s funded by the nurses’ union, the Fédération interprofessionnelle de la santé du Québec (FIQ), and has no physicians on the premises.
Canada and Quebec granted nurses certain diagnostic and prescription privileges (a practice common in more than a dozen countries including the United States, New Zealand, Australia, the United Kingdom, Ireland and the Netherlands) to reduce the workload of doctors and meet the medication needs of patients in remote areas where physicians are scarce. Nurses, for example, can prescribe antibiotics for problems like urinary tract infections, strep throat and skin infections, among other issues.
Jurick explained that the clinic’s fee structure conforms to government rules when it comes to health accessory fees, which were made illegal last year for doctors’ services covered by public health care.
Here’s how it works: Physicians bill the provincial health insurance board, the Régie de l’assurance maladie du Québec, so there’s no cost to see the doctor. However, the clinic’s other professionals — nutritionist, physiotherapist, osteopath, child educator and massage therapist — don’t get paid by RAMQ, and so they bill patients for complementary services.
For example, if a polyp or tumour is removed during a (no-fee) colonoscopy, and needs to be studied under a microscope, then the patient would pay the pathologist’s laboratory fee.
Jurick figures she’s saved the government thousands of dollars by keeping patients out of hospital emergency rooms. However, without help from the FIQ or the government, the clinic’s financial survival relies on invoicing patients, and on rent from doctors occupying cabinet or office space on its premises.
Jurick says she is operating “in technical bankruptcy.”
“Every day is a struggle,” she added. “I’m tenacious and stubborn.”
Repeated pleas to local politicians and Quebec Health Minister Gaétan Barrette have fallen on deaf ears, she said. A letter from Barrette’s administration dated from March says the clinic’s situation is under review.
A GMF or superclinic could line up government funding. But a nurse-run clinic is a new beast that doesn’t fit the physician-centred system, Jurick said. “Yet nurses’ roles have evolved incredibly. Let nurses have a seat at the table and we’d see a difference.”
“The government does not seem to see the value in nurse-run clinics,” said Jurick. “We get zero help,” yet the clinic sees 40,000 patients annually who would otherwise end up in the ER. “We want the government to acknowledge we belong as part of the network.”
Jurick is also seeking a grant of $150,000 to pay the balance on the endoscopy equipment, which was leased-to-own. The clinic performs colonoscopies, usually within two to four weeks of referral.
“Cancer screening should be done in the community, not at a tertiary care hospital,” Jurick said.
Without a family doctor to call her own, 90-year-old Joly feared she’d end up in an emergency room.
When she fell ill this winter, she’d already spent more than two and a half years on a wait list for a family doctor. The “guichet d’accèss” list referred her to TaLin.
“I was never sick before, so it didn’t matter,” said Joly, who spent nearly 40 minutes with Dr. Lee talking about her weight loss, food supplements and medications.
“I’m writing a word to your pharmacist,” Lee said. “If it doesn’t work, I want him to contact me. I don’t want to prescribe all kinds of things for you that may not be necessary.”
For some patients, the clinic is a one-stop shop. Osteopath MarieJosée Iacono says her father was among the clinic’s first patients five years ago. He lives in Saint-Basilele-Grand, a 30-minute drive to the Candiac clinic. But there were no other clinics when TaLin opened, she said, “and he had two cancers, with bone marrow transplant, and was waiting for a family doctor for four years.”
Since then, everyone in Iacono’s family has joined — her mother, her in-laws, her husband and their children. “The service is fantastic,” said Iacono, who has never taken her two children, now age 4 and 7, to a hospital emergency room because the clinic’s hours and methods are flexible.
“If my kid wakes up with a skin eruption, I’ll take a picture and send it (to the nurse) and she’ll respond within an hour,” Iacono said. And if a patient needs to see a doctor, “she’ll book the appointment for you — the same day if it’s urgent — you don’t have to wait on the phone. She can transfer the information directly to the doctor.”
Such easy access to a nurse, a filter of urgent cases, makes a huge difference, she said. “A parent will call in because a child has been throwing up all night. And they have a question, ‘Can I give him milk?’ They can solve a lot by phone and by email.”
Also, her in-laws who have health issues but travel to Spain for two months every year really appreciate having their medical files, including all the notes, imaging and tests, online and available to outof-country medical professionals if necessary.
A year ago, Iacono became staff because “I love how they work as a team” and was impressed by the clinic’s work ethic and humanistic approach. “I’ve seen the nurses go to patients’ homes because they had an infection. They really take care of their people.”
Montreal transplant surgeon Jean Tchervenkov says it’s “a model that alleviates wait lists.”
The clinic fills an important gap when it comes to primary care, said Tchervenkov, who invested in the clinic years ago as a minor shareholder.
He worked with Jurick when she was at the Montreal General. TaLin’s method, he said, borrows some elements from the collaborative approach of nurses and doctors at the Royal Victoria Hospital of the McGill University Health Centre.
“I believe in collaborative clinics. What Linda is doing is good. The issue is funding,” Tchervenkov said. “It’s running by the skin of its teeth. Like buying a brand new car and you don’t have money for the insurance.”
A parent will call in because a child has been throwing up all night . ... They can solve a lot by phone and by email.