Evaluating a Novel Integrated Chronic Disease Nurse Practitioner Model of Care

Chronic kidney disease (CKD), diabetes mellitus (DM), and heart failure (HF), are highly prevalent, constitute a significant burden on the healthcare system, contribute significantly to mortality, and frequently co-occur. Despite this, these chronic diseases have traditionally been managed separately by independent specialty teams, adding complexity to patients’ lives. Nurse Practitioners can effectively refocus specialty disease-siloed clinician systems to manage complex comorbid chronic diseases through the provision of complete occasions of care.

Aims

To describe a novel, integrated model of care provided by Nurse Practitioners for complex patients with comorbid chronic diseases.

Methods

A prospective, longitudinal study of patients with two or three chronic diseases (CKD, DM and/or HF) attending a metropolitan community-based outpatient clinic.

Conclusion

Early results indicate this clinic is achieving its goals of decreasing health service utilisation and improving patient outcomes. Failure to attend appointments is very low, and patient-reported satisfaction with the clinic was overwhelmingly high. Achievement of clinical targets and patient self-reported engagement in at-home disease self-management behaviour are high.

This ongoing project has the potential to be a considerable step forward in terms of healthcare reform. We believe that this integrated model of care is replicable, and has the potential to contribute to a shift in the way that Australia cares for patients with multiple, serious chronic diseases.

Project Enquiries

Professor Ann Bonner – ann.bonner@qut.edu.au