Abstract
Introduction: Consumers with chronic and complex conditions often have fragmented care and frequently access the acute sector. Right Care=Better Health provides an integrated chronic disease model, incorporating nurse care coordinators (NCC’s) in general practice.
Who is it for? The program targets adults in the community with complex and/or chronic conditions, who may be struggling to manage or not accessing services to support their wellbeing. The model delivers an integrated and collaborative solution providing the right care, at the right time, in the right place.
Who did you involve and engage with? The program built on learnings from existing chronic disease management programs. During the design, co-design workshops with general practices and service providers developed the model of care, evaluation framework and workflow processes, identified risks and barriers, and established a strong support network.
Quarterly Community of Practice events were used to refine the model, develop communication pathways, and share learnings.
Initially, two service designs were tried in different regions with different providers. After 12 months, the EACH Chronic Disease model of care with a lead NCC supported by three other NCC’s, was evaluated as being more successful so was continued.
A key part of the design was ensuring that NCC’s were embedded into the clinics, which involved agreeing practicalities e.g. access to GP systems.
What did you do? Five clinics trialed the program with NCC’s integrating into those clinics to ensure rapport with clinicians and facilitate information sharing. Patients were referred by clinic staff or identified through POLAR searches.
Patients enrolled for up to four months and worked collaboratively with an NCC. They were referred to appropriate services and provided with education and support to self-manage their conditions. Upon completion, patients were discharged to their GP with a comprehensive handover.
Monitoring was done using the Quadruple Aims of Healthcare, later expanded to the Quintuple Aims. Patient outcomes were measured using COOPWONCA and Patient Activation Measure (PAM). Surveys were used to monitor patient and practitioner experience. Patient demographics and staff training in cultural awareness were used to monitor equity, and service efficiency was evaluated by an external consultant.
What results did you get? What impact did you have? The program demonstrated positive impact including:
- Saving patients time when accessing health services
- Reduction in health service visits due to the integrated approach
- Improvement in physical wellbeing and quality of life
- Improved patient experience
- Improved awareness and access to disease management support
- $1.70 in savings/$1 spent
What is the learning for the international audience? NCC in general practice is an effective way to support patients with chronic and/or complex conditions to better manage their conditions, avoid hospital admissions, and experience improved quality of life.
Next steps?
- Expand the NCC model into more general practices across Melbourne’s East, benefiting more patients
- Test sustainability through supported handover of NCC role from external providers to practice nurses in participating practices
- Develop and implement a sustainable billing model
- Further evaluate health economic benefits by a health economist