Ontario has a few team-based programs for musculoskeletal (MSK) care and a number of you work in interdisciplinary/ interprofessional clinics – but there’s room for more opportunities. In this episode, we speak with Kristy Naulls, an award-winning Nurse Practitioner (NP) about how collaborative care is improving her clients' or patients’ outcomes. Kristy works at the Belleville Nurse Practitioner-Led Clinic, is actively involved in the Primary Care Low Back Pain program, and has been working with OCA’s Opioid and Pain Reduction Collaborative and its tools. She shares her experience and offers ideas you can apply to expand your opportunities to effectively coordinate care with an NP or MD.
Ontario has a few team-based programs for musculoskeletal (MSK) care and a number of you work in interdisciplinary/ interprofessional clinics – but there’s room for more opportunities. In this episode, we speak with Kristy Naulls, an award-winning Nurse Practitioner (NP) about how collaborative care is improving her clients' or patients’ outcomes. Kristy works at the Belleville Nurse Practitioner-Led Clinic, is actively involved in the Primary Care Low Back Pain program, and has been working with OCA’s Opioid and Pain Reduction Collaborative and its tools. She shares her experience and offers ideas you can apply to expand your opportunities to effectively coordinate care with an NP or MD.
Topics Covered:
Key Links to References/Resources Discussed:
About Kristy Naulls:
Ms. Naulls is a full-time Nurse Practitioner (NP) at the Belleville Nurse Practitioner-Led Clinic and is also a Certified Respiratory Educator.
She graduated from Queen's University in 2004 and worked at Kingston General Hospital for eight years before moving to Belleville to work as an NP.
Ms. Naulls has a Master’s degree in nursing and enjoys teaching NP students online as a course instructor for Athabasca University.
She is a well-regarded clinical preceptor for NP students from a variety of universities
Ms. Naulls won the Patient Choice Award from the NPAO in 2015 and is a big advocate for patient-centered care and the benefits of working in a collaborative, multidisciplinary model of care.
Episode 9: Collaborating with Primary Care: An NP’s Perspective
Introduction:
Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
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As you know, evidence-based research supports manual therapy as part of a multimodal collaborative approach. Ontario has a few team-based programs for M-S-K care, and a number of you work in interdisciplinary or interprofessional clinics, but there's room for more opportunities.
I'm Leslie. And today we're speaking with Kristy Naulls, an award-winning nurse practitioner, about how collaborative care is improving her clients' or patients' outcomes. Kristy works at the Belleville nurse practitioner-led clinic and is actively involved in the primary care low back pain program, one of the province's team-based programs for M-S-K care. She's also used O-C-A's Opioid and Pain Reduction Collaborative tools and is helping to raise awareness of this initiative.
In today's episode, Kristy shares her approach and experience integrating chiropractic care into her practice. She also offers ideas you can apply to expand your opportunities to effectively coordinate care with an N-P or M-D.
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Main Interview:
Leslie:
Thank you, Kristy, for joining me today. Why did you become a nurse practitioner?
Kristy:
I became a nurse practitioner because I wanted to make sure that I was able to help people. When I was a nurse, I felt like I was helping people, but there was a lot of times where you feel like you could do more. And to have to stop what I'm doing and go and ask somebody else to give an order for me to treat this or do this, I felt like I am able to help people a lot more if I don't have to go and do that extra step. So to have the autonomy, to go out and do the patient care without having to constantly go back and find a physician to make order changes.
Leslie:
And as an N-P, what is your area of specialization?
Kristy:
I am licensed as a primary care nurse practitioner. So I see everybody and every problem from birth to death, I have patients that are brand new and I have patients that are over a hundred and we deal with every system in between. So I do have a very broad range of things that I deal with in primary care.
Leslie:
And somewhere on the way, you discovered coordinating care with chiropractors. When and how did this happen?
Kristy:
As a nurse practitioner in primary care, we often have people come and visit the office and tell us about the services they offer in the community. And we have a chiropractic clinic that was new in the area. They decided to come in, introduce themselves and tell us about the services that they offer.
Kristy:
And while they were there talking, I thought they sounded like they had a lot of interesting ways to address different problems that I hadn't thought of before. I found they were doing the active release techniques. They were explaining a lot of the science or the mechanisms behind why adjusting or correcting the area like the pelvic would help with headaches and neck problems, which I hadn't really thought to connect all those dots before.
Kristy:
So then I decided that I would go and see the chiropractor myself. You know, everyone that has these aches and pains that they think, oh, I wonder if I could get this a little bit better. So I went to see one of the chiropractors myself to try out their services and found that it was actually very helpful and they were really good educators. We would talk a lot of the science behind why this and that.
Leslie:
Okay. And how long ago was this?
Kristy:
That would've been about 10 years ago.
Leslie:
And so when did you actually start integrating this into your care as well?
Kristy:
So after I'd seen the effects on myself and done some more research through some of the resources that they provided (they lent me textbooks, they pointed me towards podcasts that I could listen to and different studies that I might want to look at.) Once I looked a little bit more about it, I started talking to patients and saying, have you thought of this as a treatment option for yourself? And some patients were very on board because they hadn't thought of treating their symptoms that way either. And some of them were a little hesitant, but because I tried it, I was able to say, well, why don't you try it? And then we'll get back together and see how it went. And that seemed to kind of open the door. And then these chiropractors I was dealing with were very good to send me notes back. So I could send them a letter and say, here's what I see. Here's what I'm wondering. And they would reply, which I thought was a great way to be.
It wasn't long after that we ended up having the opportunity to be part of the low back pain pilot project. And when that came up, we were able to have a chiropractor that worked within the clinic and then it was great, because we could walk right into his office and have a discussion about different M-S-K complaints and trying to figure out what's going on, whether or not he felt it was something that he could correct or deal with or make an improvement upon. Sometimes it was the other way around where he would see patients who presented with back pain, but they weren't responding as they should. So he could reach out to the nurse practitioners and we could do maybe a pelvic exam, maybe an abdominal exam, or look deeper to see what might be going on there.
Leslie:
Is there anything that stands out as the most surprising thing that you discovered when you started coordinating care with chiropractors?
Kristy:
The most surprising thing was that they have a holistic approach. So they don't necessarily just look at the mechanics and say, here's your problem, here's how we're fixing it. When I went to see them, they asked a lot of questions. They're trying to connect a lot of dots, but they're holistic in their approach to patients.
Leslie:
And if you had to give recommendations to other nurse practitioners, what would you say based on your experience?
Kristy:
That's a tough one. I have now become an advocate of manual therapy. I think that there's a place for it in treating patients who have obvious M-S-K complaints, but even those concerns where we can't figure out what's wrong with them. You know, we've got people who've got pelvic floor issues and I find that just incorporating the manual therapy as another treatment option opens the doors for the patients. It helps them in so many ways. I've got patients that I've sent out and they have come back and said, I didn't think it would help me as much as it did, and I'm doing so much better in so many other ways that I wasn't even intending on. I would tell the nurse practitioners out there that they need to keep in mind that it isn't "a one provider fixes everything" model of care anymore. We really need to be thinking about all the options that are out there and helping patients navigate the system so they get the most optimal treatments.
Leslie:
Absolutely. And how does this benefit you and other nurse practitioners or other primary care providers when the patient has success?
Kristy:
It's very beneficial when the patient has success because they're not doing that revolving door where they keep coming back to us with the same complaint. Oftentimes because we can identify here's your problem, and we can even give them some ideas on how they might be able to help themselves feel better. But if we don't get to the root of the problem and do the rehabilitation piece, then they continue to come back with the same complaint. So we treat the pain, we give them some ideas of perhaps some stretching, perhaps a change in activities, but we're not musculoskeletal specialists the way that chiropractors would be. So we're doing them a disservice by not connecting them with someone who is a practitioner of a manual therapy because we're just going to come back and the problem will never really get addressed at the root.
Leslie:
Absolutely. So now that you're a manual therapy advocate, what steps do you go through to assess a patient for manual therapy?
Kristy:
I would go through a discussion with the patient on I'm trying to find out where the problem lies. Trying to decipher whether it's a musculoskeletal problem or if it's an organ problem, or if it's even mental health, that's causing the symptom. If I've gone through my assessment and determined that the most likely cause is an M-S-K concern, then I'll do a referral to have an M-S-K specialist have a look at them. And that would be a manual therapist.
Leslie:
So once you've gone through that assessment and you've decided that the patient is a good candidate for manual therapy, how do you select the type of manual therapy?
Kristy:
So I'll talk to patients about what their experience has been. Is there a provider that they're most comfortable with and I'll ask them, what about that provider they're more comfortable with. I talk to them about the different options. I talk to them about the different skill sets that the different providers have. And then I tell my patients, they're the driver. They get to decide where they're going to go. And I go through the benefits and risks of the different providers that are out there and answer questions because there are a lot of myths.
Kristy:
The biggest scare people have is regarding the manipulation of the neck. So I will tell them that the evidence is showing that the risks are very low of having any problems from the chiropractic treatment, aside from some aches and pains. But I also tell them that chiropractors are trained professionals. They're registered and they know what they're doing. And that patients should address those questions directly with the provider that they're seeing so that they can get an idea. And I tell them, maybe you don't want to have your neck manipulated, then tell the provider that. Maybe they can start with a manipulation somewhere else. Maybe you don't need manipulation at all. They just need an assessment and an opinion to start. And then they can talk about the treatment.
Leslie:
Yeah. Because as you know, patient preference is a key part of chiropractic care.
Kristy:
Yeah. I find a lot of times patients knowing that I'm making the recommendation is a big step in the right direction. And then once they meet a chiropractor, I tell them, see how it feels. If they don't feel like the right fit for you, then maybe we need to find somebody else or maybe we need a different service for them.
Leslie:
Okay. Now when selecting a chiropractor to refer to, what are your priorities? Is there a top three or how do you select one that you will refer the patient to?
Kristy:
First of all, they'd have to be somebody that I've met before or have heard good things about. I don't just make a suggestion. If Google says there's these 20 chiropractors, I don't say well just call one of them. I'll often look for people that I've either worked with in the past and have a good experience, or I've had patients come in and say, oh, I worked with these chiropractors and they're really good. Then I will let patients know that. And I'm very careful to let them know whether it's somebody that I have worked with or if it's someone that I have heard is good. And I tell them that they need to go and ask their friends and family. Another thing would be, I want to refer them to chiropractors where we've seen that they've made a difference and that the patients feel like they're part of the care, and they understand the problem so that they're able to understand why they need to change their behaviours at home.
I like to work with clinicians that are doing the treatment and educating the patients so that they can walk away with the knowledge they need to prevent them from coming back. I like chiropractors that say, you know what? I want to see you till you're better, but I don't want to see you forever. I try to tell patients that as well, because the goal isn't that they are now going to see a chiropractor three days a week for the rest of their life unless they want it to be something like that. The goal is to treat the problem and fix the ways that whatever's landed them where they are, and then decide from there what we’re going to do.
So that's two, and then third, accessibility. Are they easy for people to get to? So if I have a low-income person, I need to go somewhere where there's maybe a bus stop nearby. Or I've had experience before, where I've been able to talk to the chiropractor and say, do you have a seniors' discount, do you do a pro bono visit just to get them through the door and see if they can make any improvements there? And then we discuss how the patient can maybe fit that into their budget.
Leslie:
And what was your biggest barrier to collaborating with a chiropractor when you started?
Kristy:
The biggest barrier was communication. If they can see a patient and notify me or they say I've seen your patient for this problem, and I'll let you know if I have any concerns or if they're not getting better with treatment, I find that it's really helpful, but people tend not to send that right away. We don't necessarily have to talk all the time, but they know that if they have a concern, they can reach out to me. And I know that if I have a concern, I can reach out to them. And I find that the team-based or collaborative approach tends to work better for the patient. Then we're both on the same page, know where each other is kind of thinking that the problem is.
Leslie:
Is there a type of communication mode that works best?
Kristy:
For me faxing is the easiest, because it's easier to keep the patient information confidential through fax than email. And it's something that I can get to when I get a minute to get to. If it's something that's more urgent and something needs to happen today or tomorrow then a phone call will be better. But for the most part, a fax of here's your update and what are you thinking? Or would you consider an x-ray or whatever? Maybe if I can just send them a big letter and say, I saw Mr. Smith today in clinic and here are my concerns. I know he's seeing you. If I can then fax that out to them and they'll get it and they'll be able to address those when they see him, then I find that works well.
Leslie:
Okay. What about other barriers that our members may face? How can they address them best?
Kristy:
I can imagine the chiropractors will find communication will be a barrier. They'll probably feel like they can't reach out to primary care, but they should introduce themselves. Even sending out like a quick letter or something to the different providers in the area saying, Hey, I'm here. This is the services that I offer, and these are the areas that I specialize in. It just helps us to kind of queue that we can think about that. Even hosting an open house or something where people can stop by and ask questions and see who you are. But really just getting your name out.
If you're brand new at this, and you are looking to make connections with primary care, then you have to reach out. Primary care providers don't tend to look and see who's new in the area and go find them. It's usually whoever's new comes finds us. That would be one way. And the other would look for the barriers on your end. If it's access, then try and improve access. Whether it be hours, whether it be trying to see if you can advocate for a bus stop for your site, whatever it may be. And I think working as a team with other providers is going to be useful as well.
Leslie:
How have you found collaboration affected by the pandemic? Positive, negative, and what's changed?
Kristy:
I think there's both positives and negatives. There's a lot of services that moved to being phone-based, especially in primary care, because we weren't allowed to see a lot of people in person. But being able to collaborate with the providers like the manual therapists that could do the assessment and then send me a note back to say, Hey, I saw this patient, here's the assessment. I also found collaborating with the different clinicians so that patients are not having to have the same assessment done multiple times.
If I know when I talk to them that they'd benefit from an M-S-K assessment, then I could bring them into the clinic and I can do a general assessment. But I'm not a skilled M-S-K clinician, it's not my forte. I do a lot of things. I do a general assessment to try and tease out where the problem lies, but if they know they need, let's say, a low back assessment, sending them directly to a chiropractor for that assessment was very helpful to patients so that they don't have to wait again to get in to see a chiropractor. We could have the treatment done and them feeling better within a really short period of time.
Leslie:
So very convenient for the patient. And also, needless to say, it can affect the outcomes?
Kristy:
I think so. And I think it forced us to be a little more collaborative because we want to know what was the finding for that assessment, so that I don't have to bring them in for another assessment.
Leslie:
We also have an opioid crisis and I think you've seen some of the challenges there as have our members.
Kristy:
Absolutely. I find a lot of patients come in with their mind already made up of what they want when they leave. So a lot of times what I have to do is educate them on, well maybe we need to change what you are intending on this so that we actually address the problem, and don't just treat it with medications or opioids.
Leslie:
Can you hypothetically describe a case study where you had a patient come in, who had an opioid dependency and where manual therapy, potentially chiropractic, made a difference?
Kristy:
I have a number of cases. When nurse practitioners were given the scope of practice that was allowing us to write prescriptions for narcotics, we adopted a lot of new patients to us that we hadn't previously been able to provide the opioid care for. And then throughout all of our education, we're trying to reduce the amount of opioids in the community and reduce people's dependency on them.
So it became a big discussion point. Why are on? What is the problem we're trying to treat? And then having discussions about maybe that problem be addressed as opposed to covering up with the pain medication. And I have a number of these patients that we put through our low back pain project at the clinic that we were able to get them completely off and they're doing well, even though they'd been on them for many years. Some of the patients I adopted from another provider were on opioids for 10 or 20 years for chronic back pain or chronic knee pain or chronic shoulder pain. And working with the chiropractor, they've been able to reduce and remove the opioids and they continue to do well. That's why I think at our clinic, we are fortunate enough to have our funding changed from a pilot project to base funding. So now we have a permanent position for a chiropractor because the benefits were noted when we were doing the project.
Leslie:
We hear a lot about M-Ds being under pressure in terms of not prescribing to the extent that perhaps was done in the past. Is that same type of pressure being put on nurse practitioners?
Kristy:
When you're looking at nurse practitioners, we didn't have access to narcotics in the past. So when we picked it up about five or six years ago, we were trained about opiates. There's a lot of training about how to avoid using them, why they should be a last-ditch effort, and when you do use them to minimize the amount you're using and the amount of time you're using them for. And there's all these guidelines coming out about chronic pain management and whatnot. There's a lot of discussion around managing pain through manual therapy and non-pharmacological means as well. So we're trained a little bit differently with where we put narcotics on our list of things to try for pain. So we have a little bit different approach than physicians, who'd been doing this for a long time.
Leslie:
Now, how did you learn about O-C-A's Opioid and Pain Reduction Collaborative?
Kristy:
I learned about beds through our chiropractor at our clinic when we did get funding for the low back pain pilot project, our chiropractor, Dr. Bruce Flynn, came on board and he got involved in working with this collaborative. And when he was gearing up for retirement, he mentioned that the collaborative was looking for a primary care provider to get involved and work on the collaboration piece so that we have a primary care provider on board. And that's where my invite came from. And I did a little bit of research and I've been part of the collaborative ever since.
Our clinic is a not-for-profit clinic and these chiropractors are salary-based. So there's no fees for patients right now. The services are essentially available to clients of the clinic. I would love it if every primary care office could have a chiropractor on staff, I can't say how good it is for the patients to be able to have that service right onboard. We don't have to worry about access problems. We don't have to worry about financial barriers. And the barrier of education is a little bit easier too because we can have them do education for the staff, education for the clients, to teach people about what chiropractors can offer.
So I've been finding that I am spoiled now that I have a chiropractor on site but that doesn't mean I don't use chiropractors in the community. Cause the truth is our chiropractor in the clinic can't see everybody. There's too many people.
Leslie:
Yeah. We know our chiropractors are talented, but there's human limitations. So with the Opioid and Pain Reduction Collaborative, which we've talked about a lot on the podcast, we've developed a lot of tools for primary care, as well as for chiropractors to communicate with primary care. What do you think of the collaborative and its various evidence-based tools?
Kristy:
I think it's brilliant. There's lots of things that have come out of this and lots of benefits to both sides. Collaborative approaches are going to be much, much better for clients, and the evidence has shown that. I find it's exciting to see these kinds of things being created right now so that we can see the benefits. I like that we're starting to incorporate the expertise of the different providers that are out there. The collaborative is going to be a game-changer, I think, in managing M-S-K pain. I think that it's going to start changing the way people look at their treatment plans and people are going to start seeing that there's benefit in incorporating manual therapy at the beginning.
Leslie:
Absolutely. Now with the various tools with the Opioid and Pain Reduction Collaborative, have you used these tools and how?
Kristy:
C-E-P's clinical tools are the ones that I'm most familiar with, the manual therapy and primary care and the core back tool. Those are the two things that I refer to the most. And I honestly, at this point feel like I have them both memorized because we use them so often. But I find that it helps me teach, not just myself, students that I work with, but also patients. Here's the evidence. Here's how we're going to flow through this. This is the way that we will make our decisions. And this is why I'm telling you that this is the next best step for you.
Leslie:
Okay. So the first tool you mentioned is the manual therapy as an evidence-based referral for M-S-K pain, a clinical tool that O-C-A hired the Centre for Effective Practice, or C-E-P, to develop for primary care providers. And you know, since it's launched in 2020, this tool has been downloaded more than 5,000 times. The other tool you mentioned is C-E-P's core back tool, which we feature on our webpage for other healthcare professionals. What do you think of the various forms to help coordinate care that O-C-A developed? If you received one of those forms completed, would it be helpful?
Kristy:
I think so. I think they're a good way to summarize the information. I think that it keeps everybody aware of where the treatment plan is intending to go and where the patient currently sits in that. I think it's a great communication tool.
Leslie:
So what is the top way a chiropractor can provide extra value to a nurse practitioner?
Kristy:
Education. I think that both clinicians and clients need education on the importance of body mechanics, the importance of movement in terms of preventing a lot of their aches and pains that they're complaining about. I think that educating people on why is it important for them to pay attention? And why is it important for them to address M-S-K concerns before they become a chronic problem? I just feel like there's a lot on both sides of clinicians and physicians that don't really have all the information. And I think there's a lot of patients that don't. The people that we all deal with could benefit from education.
Leslie:
Okay. That's great to know. And as you know, there's research that's ongoing. And so certainly chiropractors can keep primary care up to speed with some of the many changes or developments in the research that's coming forward.
Kristy:
Because I think if it's your forte and you live this, you know it. Right? But when you're a Jack of all trades, like a lot of primary care providers are, we know the basics. We have so many patients that we spend a lot of time educating them on the benefits of all these things. So if you have any good resources to share with your local nurse practitioners or physicians, I'm sure that would be good. Or if you're going to be hosting say a talk or something, we can connect patients to say why don’t you listen to this or whatever it may be. I think we can educate the community as well.
Leslie:
Okay. Thank you. Any final recommendations that you have for our members in terms of how to best coordinate care with a nurse practitioner or primary care in general?
Kristy:
I honestly think it comes back to networking. Just go and meet the people that are out there. We all have different parts to play in the care of the patient. And I think it's time for us to start all working together. So really networking, get teams out there and find out what their stance is on it. Do they have questions? Do they have biases? Do they have concerns? And educate. Because a lot of times those things we don't understand well are the things we trip over when we're trying to provide optimal care to patients.
Kristy:
I'm excited about it. I think there's so many opportunities to collaborate in the future.
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Outro:
Thank you, Kristy, for sharing your experience, insights, and tips on how our members can initiate and sustain effective interprofessional relationships with primary care providers.
We'll be back in July with an episode focused on Ontario's rapid access clinics, or R-A-Cs, another team-based approach to M-S-K care. In that episode, we'll discuss how you can participate and support the R-A-Cs. I hope you'll join us.
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