An integrated chronic disease nurse practitioner clinic: Service model description and patient profile

Abstract

Background: One common cluster of chronic conditions — chronic kidney disease, diabetes mellitus and heart failure — places a significant burden on the Australian healthcare system. In combination, these conditions complicate treatment, increase rates of hospitalisation and carry a poorer prognosis for survival. Current health services are organised around single conditions, making coordination of care more difficult and adding complexity to patients’ lives. Aims: To describe an integrated model of care provided by nurse practitioners for patients with multiple chronic diseases. Methods: A prospective, longitudinal study of patients with two or three chronic diseases attending a community-based nurse practitioner clinic. On entry to the clinic demographic and clinical data were collected from patients and health records (n = 121). At six months a subgroup (n = 70) also reported their satisfaction with the clinic. Findings: Over 18 months the clinic provided 925 appointments to patients aged between 27–90 years. Most (79.2%) had chronic kidney disease as one of their diagnoses. At baseline, blood pressure and glycosylated haemoglobin targets were achieved by 66.4% and 83.2% respectively, although only 7.1% had a healthy-range body mass index. After six months of attendance, there was high overall patient satisfaction with the new service (98.7%). Discussion: Nurse practitioners can reform healthcare delivery through innovative person-centred models of care, breaking down the siloes of treatment for chronic disease. Conclusion: In the current and growing context of multi-morbid chronic health conditions, integration of care within and across organisations is required to meet future health care demands.