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/ Issue Date: October 01, 2003

Vol. 11 •Issue 10 • Page 26

Comprehensive Continence Care: The Role of the APC

By Helen Carcio, NP

As my grandmother aged, she experienced frequent episodes of incontinence and was horrified when she leaked or smelled of urine. My grandmother felt loss of control, fear, frustration and shame. Her only option for controlling leakage was cloth diapers. Fortunately, treatment and management options have changed dramatically since then. In addition to simpler surgical techniques, today's conservative, nonsurgical approach to the treatment of incontinence has changed the face of continence management. Women who are accurately diagnosed and treated are now able to take back control of their lives, unhindered by incontinence. Unfortunately, thousands of women are untreated and do not have access to care because there aren't enough continence centers to treat and manage this widespread problem.

Scope of the Problem

The National Kidney and Urologic Diseases Advisory Board estimates that incontinence affects a staggering 13 million people, most of them older women. Because incontinence is often a hidden disease due to associated embarrassment, researchers believe it is widely underreported and that the number of women affected may actually be as high as 26 million. Untreated, incontinence can lead to embarrassment, depression, decreased sexual activity, decreased job opportunities, powerlessness and social isolation. It is a socially, emotionally and physically devastating problem affecting 20% to 40% of elderly women.1

Critical demographic trends are changing the nature of the country and thus the health care landscape. The fastest growing segment of the population is the aging baby boomers, now in their 40s and 50s. The proportion of U.S. residents between 45 and 65 has dramatically increased over the last decade and will continue to do so during the next 10 years. As the number of elderly people rises, so will their need for health care services, particularly incontinence treatment.

When so many women are affected by incontinence, it is surprising that more services aren't available. Treatment of this problem is not consumer driven, however, because so many women do not seek help. Women are reluctant to discuss incontinence even with their primary care providers. The reasons are many and varied. All women need current, accurate information to learn that their problem is common and treatable. Table 1 lists some of the most common reasons why women are silent about incontinence.

Table 1: Reasons Why Women Do Not Report Their Incontinence

  • They believe it is a normal part of the aging process — something they have to learn to live with.
  • They are able to limit fluids and thus decrease urination, increasing the risk of dehydration.
  • They are afraid they will be institutionalized. (Incontinence is the major reason for admission to nursing homes.)
  • They are too embarrassed to admit to such a "shameful" condition.
  • They believe they will be socially isolated. (Perhaps they already are!)
  • They are able to rely on incontinence products.
  • They don't realize or believe that they are not alone.
  • They feel powerless and are resigned to their situation

A Fit for the Advanced Practice Clinician

The lack of available information and treatment for incontinence provides an exciting practice and business opportunity for nurse practitioners. The goal of this article is to generate enthusiasm for the expanding role of nurse practitioners in the establishment of nurse practitioner-managed continence centers. I established and now operate two such centers, at Pioneer Women's Health in Greenfield, Mass., and Grace Urological in Brattleboro, Vt.

Although I never thought I would prefer working with elderly women, I see my grandmother in their faces and derive much pleasure from this patient population. For many years I have been dedicated to the health needs of women, first specializing in adolescent contraception, then infertility, then perimenopause and menopause, and now incontinence. It seems my career has evolved and progressed parallel to my own life span. The administrator of my continence center has told me that I have reinvented myself more times than Madonna. But that is what being a nurse practitioner is all about — being creative and responsive to changes in health care

Nurse practitioners are emerging as frontline providers in the diagnosis of incontinence and treatments to restore continence. The conceptualization, establishment, marketing and management of a continence center or program offer an exciting and rewarding opportunity for an NP. You can accomplish this by establishing an independent practice or collaborating with other health care providers. Reimbursement barriers have been removed or minimized in most states, with a broadening of authority and ability to receive direct payment for services provided. NPs are ideally suited for the role since most have the patience, motivation, teaching skills, clinical knowledge and enthusiasm necessary to support and motivate women as they make their way through an incontinence treatment program.

Taking Stock of Your Resources

This adventure is not for everyone. It requires a special personality. So begin with some self-analysis. Are you creative, positive, dedicated, patient, attentive, motivated and motivating, knowledgeable about incontinence, and free of heavy family responsibilities? Do you have a flair for business — an entrepreneurial spirit? Do you have access to the following personal and professional resources:

  • credibility as a nurse practitioner expert
  • potential to generate financial support
  • an experienced consultant
  • a collaborating physician
  • surgeons to refer to when necessary
  • access to the Internet for educational support
  • incontinence or other focused treatment centers as models for your venture
  • state requirements and regulations
  • billing codes for reimbursement?

To be licensed in most states, NPs must follow established clinical guidelines. An excellent resource and appropriate guide for the nurse practitioner who wants to manage an incontinence center is a federal guideline titled Urinary Incontinence in Adults: Clinical Practice Guideline, published by the Agency for Healthcare Policy and Research.2

Conceptualization

As the organizer of a continence center, you must be committed to the venture and have the motivation and the know-how (or at least know how to get it!) to complete the project. Consider all options and anticipate potential problems. First, obtain or perform a community assessment. It is often best to offer continence services in a community you are familiar with. Determine the existence of any other continence centers in the surrounding areas. What would draw women to your proposed center? What is the population of women, particularly older women? This information is usually on file with city offices or at local hospitals that have obtained community grants. A formal business plan is necessary and is beyond the scope of this article, but many communities have agencies that can assist with the formulation of such a plan. You can also refer to the Business Guide for Nurse Practitioners published in the June 2003 issue of ADVANCE for Nurse Practitioners (Reel SJ. Developing a business plan. Getting down to specifics. 2003;11[6]:53-54,90). Additionally, computer programs that outline how to create a business plan are available.

An initial assessment of your concept should include deciding on a mission statement and objectives. A mission statement and related objectives will help guide your course of action and help clarify your thinking for potential grant writing. The following is a sample:

Mission Statement: To establish a holistic, community-based continence center to provide comprehensive, compassionate and high-quality care, including diagnosis and management of women who are incontinent.

Objectives:

  • to increase services, expand productivity and increase revenue for an existing practice
  • to increase access to health care for women who are affected by incontinence
  • to decrease the number of incontinence episodes through the diagnosis and management of incontinence
  • to provide a conservative alternative to the surgical treatment of incontinence
  • to expand the work force by making it possible for older women to work productively well into their later years
  • to prevent early institutionalization
  • to partner with existing community resources to meet a community need
  • to help women maintain the dignity they deserve as they age.

These simple objectives contain key words that can be used when applying for grants: lack of control, dignity, women, aging, community and conservative treatment.

Practice Options

The name of your center is important, so choose it carefully. Think positive. The name "continence center" sounds more positive than "incontinence center." A more general name might also work, such as "The Center for Bladder Health" or "Urology Services for Women."

Your center can take one of many forms, ranging from a comprehensive treatment center to a program within an established women's health center. Decide whether to set up an independent or collaborative practice. The term "center" usually indicates a more independent setting where continence diagnosis and treatment are the main functions. The term "program" tends to refer to a specific program for continence that is part of a larger office, such as a women's health center. I will use the broader term "center" for the remainder of this discussion.

An independent practice requires more financial resources and time than a collaborative arrangement. Many NPs do not have a strong business sense, yet have many of the other characteristics necessary for success. Therefore, I believe that a collaborative model is the most realistic for many NPs. Urologists, urogynecologists and obstetrician-gynecologists in your community are likely to be interested in considering a thoughtful and organized plan for managing incontinence. In most cases, it is a service they would like to offer but that they probably do not have the time or energy to organize. They might have the financial resources available to help you do so once they appreciate the revenue-generating possibilities. This collaborative model makes the most sense since it presents the least amount of financial risk. You should approach the collaborating physician of your choice with a detailed plan that clearly demonstrates how such a center could increase existing services, expand productivity and generate revenue.

Choosing a Site

Tour potential office space and discuss space requirements with your collaborating physician. Since you will be dealing with many elderly women, select a place that is easily accessible on the ground floor or by an elevator, with nearby public transportation. One large room to use 1 to 3 days a week should be adequate at first. Next, determine the personnel required. At minimum, you need a competent RN to assist with the program.

Explore lease-to-purchase options for equipment for pelvic floor rehabilitation and urodynamic testing. Specific equipment needs are discussed later in this article. Research the availability of local and regional grants to assist in capital equipment acquisition as well.

MarketingApproaches

Marketing strategies are an integral part of your business plan and should target women and health care providers in the community (Table 2). The major challenge is to dispel myths and misconceptions about incontinence and to promote the positive aspects of conservative treatment modalities.

Table 2: Target Groups for Marketing

Women in the Community

Socially mobile

Homebound

Institutionalized

Providers in the Community

Primary care providers

Women's health centers

Specialty practices

Your marketing focus should be on developing strategies to reach older women in the community. Three groups of women need to be identified and approached: the actively mobile, the homebound and the institutionalized. Good sites for reaching actively mobile women are beauty salons, community and church groups, and fitness or senior centers. To contact women at home, use newspapers, weekly circulars and local cable television or radio programs. Visit assisted living facilities and senior apartment communities to meet the administrators and assess the need for your services.

Community Education

Promote community education about incontinence. One way is to make a presentation to area hospitals. Hospitals may want to partner with you to promote the center, since it provides a valuable community service. The title of the presentation is important. Remember that this condition is still considered embarrassing. The first presentation about my center was titled "Treatment Options for Urinary Incontinence" and no one attended. I called the second presentation "I am Too Young for This — An Approach to Bladder Health," and I had a large audience. Practice your presentation on smaller audiences, then organize something larger. For example, arrange to be the luncheon speaker at a senior center.

Keep the presentation easy to understand. Use plain language, avoiding unfamiliar medical terms. Emphasize that incontinence is a common, widespread problem that is definitely treatable. Inform your audience that by using conservative measures, continence is improved in 85% of cases.3 Discuss strategies to regain bladder control, such as pelvic floor rehabilitation, bladder retraining and pharmacologic treatment. Review simple methods such as avoiding bladder irritants. Do not ask personal questions in this atmosphere.

Incontinence Screening Day

Organize an incontinence screening day as part of your marketing plan to reach community women. Consider partnering with a local hospital and include osteoporosis screening or breast cancer risk assessment evaluation. An additional source of funding for this day may be pharmaceutical representatives. It's a nice touch to offer a healthy snack. Each woman should be scheduled for a 15-minute visit and progress through a series of stations. At the first station, a nurse performs a dipstick test of her urine sample and records the results. At the second station, the woman fills out a risk assessment questionnaire. At the third station, you make recommendations based on the dipstick results and questionnaire. Each woman should leave with a brochure about your practice and a more comprehensive health history form to complete on her own. Give each woman the opportunity to schedule an appointment. Have a sign-in sheet to build a list of names and addresses for future mailing lists. You could also have a raffle (gift basket, recipe book) that they would have to fill in their names and addresses.

Professional Networking

It is essential to make providers in your community aware of your new center. Initially you could arrange a luncheon information session at larger medical offices, speak at grand rounds or provide an evening dinner program. Consider seeking sponsorship by a pharmaceutical company.

At each session or event, discuss the various types of incontinence and the related symptoms. Explain the diagnostic services your center offers, such as urodynamic testing. Review pharmacologic and nonpharmacologic approaches and provide statistics about the success of pelvic floor rehabilitation. Explain who and how to refer to your center, and supply referral forms and practice brochures. Inform the providers about new treatment options and the availability of new state-of-the-art diagnostic services.

Many primary care providers do not have any interest in treating incontinence but would be happy to offer this service to their patients through referrals, particularly if the treatment is conservative. Since many women are reluctant to broach this embarrassing subject, all providers must ask their patients about bladder control. Suggest that providers do this by including a question about urine leakage on their patient information forms.

Be sure to send an initial marketing letter to all area practices, hospitals and extended care facilities in surrounding communities. Then, send a follow-up letter after each initial consult and enclose more information about the program and its potential for success. At the conclusion of a patient's treatment program, send a summary letter to her referring provider that explains her progress and reinforces the success of the center.

Clinical Services

The rest of this article discusses the backbone of your center — clinical services. As part of your business plan, determine which services you will offer. Essential services to provide at a continence center include:

  • assessment and evaluation of incontinence
  • diagnostic procedures such as EMG and urodynamic testing
  • counseling on dietary modification, including identification of bladder irritants
  • medications, particularly anticholinergics
  • identification and treatment of atrophic vaginosis
  • behavioral modification
  • pelvic floor rehabilitation using biofeedback and electrical stimulation
  • mechanical support using pessaries.

Assessment and Evaluation

Schedule an hour for each initial visit. Many elderly patients do not have a long attention span. Try not to give too much information at once. It may be necessary to repeat much of the information at subsequent visits. Mail the assessment form to the patient prior to the first visit and have her bring it to the visit for discussion. Begin with an assessment of the home physical environment, including the location of toilets, and suggest any modifications that might be helpful.

A comprehensive history and physical examination are essential. The focused history will help determine the type and extent of urinary incontinence. The physical examination should include a pelvic examination to evaluate anatomic support, assess muscle tone and determine neuromuscular innervation to the sacral dermatomes. Perform a bimanual exam including a rectal examination to detect masses or suprapubic tenderness.

In addition to the physical and history, obtain a post-void residual to determine if the patient is completely emptying her bladder. This can be done by catheterization or bladder scan. Urinalysis and urine culture rule out infection and other disease states. A catheterized specimen could be used for this, since the urine sample is free of vaginal secretion contamination and many elderly women find it difficult to do a clean catch. (At your new center, remember to always place a table next to the toilet where a woman can place the urine collection cup and wipes.) A collection hat can also be helpful, especially with the elderly. It seems many women have a "shy bladder" and although they have a problem with incontinence, they cannot produce a drop when asked to do so!