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A Practice-Based Model of Care Coordination for Chronic Disease Management: The Role of Nurses in General Practice

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A Practice-Based Model of Care Coordination for Chronic Disease Management: The Role of Nurses in General Practice
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  1 A Practice-Based Model of Care Coordination for Chronic Disease Management:The Role of Nurses in General Practice Elizabeth Kendall 1  Heidi Muenchberger 1,3  Carolyn Ehrlich 1  Ronita Neal 1  Kim McFarlane 1,3  Kylie Armstrong 1,2   1. Centre of National Research on Disability and Rehabilitation, Griffith Institute ofHealth & Medical Research, Griffith University, Meadowbrook Q 41312. General Practice Queensland3. Queensland Health Southside District Place-Based InitiativeThis paper was prepared as part of a primary health care research collaborationbetween Griffith University and General Practice Queensland. The work was madepossible by funding from the Gold Coast Division of GeneralPractice, Queensland Health and the Motor Accident Insurance Commission  2 Abstract: This paper explores the role of practice nurses in the coordination of care for peoplewith chronic conditions. A sample of practice nurses and general practitionersparticipated in a focus group discussion to identify their perspectives on the role of thepractice nurse and the specific tasks that might be conducted by practice nurses. Thefindings suggested that there was considerable confusion for both parties aboutcoordinated care, but a commitment on the part of nurses to engage in activities thatsupported people to get the services they needed. Five themes emerged from the datathat indicated the need for a developmental and well-supported implementationprocess. There was a lack of conceptual clarity about care coordination, the need forcultural change within the whole practice, increased capacity to develop internal andexternal partnerships, role definition and a full understanding of the financial models thatcould support care coordination. The tasks that could be performed by practice nurseswere organised according to the 5As framework.    3 According to Rothman and Wagner (2003), if primary health care is to meet the needsof people with chronic conditions, then it must be defined by three features, namelycontinuity, comprehensiveness and coordination. They noted that any efforts to improvethe coordination and quality of care must acknowledge the fact that most consumersreceive the bulk of their care in general practices and are likely to do so for theforeseeable future. Consequently, general practice is thought to be an appropriate sitefor care coordination, particularly because it is focused more on the person than on thespecific illness (Freeman et al., 2003). From this vantage point, however, it is necessaryto engage a range of specialists and allied health or community support workers in theholistic management of a consumer’s needs. Further, given the time demands ongeneral practitioners (GPs), successful chronic illness care programs rely heavily onnon-physician personnel. Thus, the shift towards primary care coordination hasnecessitated new (or perhaps revisited) roles for traditional general practice staff, suchas nurses, practice managers and receptionists. Care Coordination: A Source of Consumer Continuity From the perspective of the consumer, a sense of continuity is likely to emerge from asystem that provides a “coordinated and smooth progression of care from the patient’spoint of view” (Freeman et al., 2003, p. 624). This progression will depend on thecombination of coherent information transfer, inter-professional and cross-servicecommunication, interaction with a parsimonious team of professionals and theopportunity to develop an interpersonal relationship with one or more members of thatteam. In addition, there must be flexibility to adjust to the needs of the individual as theychange over time.  4 According to Haggerty et al. (2003), three types of continuity are important toconsumers, namely informational, management and relational. The relative importanceof each type of continuity will differ depending on the stage of the treatment continuumconsumers are currently experiencing, their context and their personal responses. AsHaggerty et al. noted, information is a thread that links together one service episode toanother, inherently creating continuity. Whereas documented information tends to focuson medical conditions and treatments, personal information may not be transmitted inwriting and tends to focus on the person and their preferences, values, needs, context – both types of knowledge are equally important to continuous service provision.Management continuity is achieved when services complement each other and aredelivered in a timely and integrated way, with both consistency and flexibility as needed.Relational continuity bridges the gap between past services and current services andprovides a link to future services. Haggerty et al. suggested that this type of continuity isperhaps most critical to consumers as it relies on access to a set of commonprofessionals who give a sense of predictability and coherence to the fragmentedservice system.Surprisingly, there is evidence that relational continuity may have more to do with thenature of the entire practice setting than with the individual GP. As noted by Freeman,Olesen and Hjortdahl (2003), in contemporary health systems, GPs are often workingwith transient patients, minimizing their capacity to develop relational continuity.Although this situation would be expected to result in poorer outcomes, Parkerton,Smith and Straley (2004) found that physician continuity was unrelated to any patientoutcomes. However, practice coordination (i.e., shared practices across a stable teamof health professionals) was associated with increased levels of disease screening andbetter chronic disease management. Thus, relational continuity may not be dependent  5 on the individual GP, but rather on the capacity of a team of health professionals toprovide a consistent and coordinated service. The Role of Nurses in Care Coordination To address the need for coordination, it is critical to improve chronic care expertise inthe health workforce (Wolff & Boult, 2005). In this regard, Sibbald, Shen and McBride(2004) noted that any plans to improve the effectiveness, efficiency and responsivenessof health systems must incorporate a change in skill-mix (i.e., the match between therequirements of the system and the competencies within and across teams of healthprofessionals). According to Sibbald et al., such changes are achieved by enhancingthe role of some professionals, substituting one type of worker for another, delegatingtasks up or down a traditional disciplinary ladder or through innovation (i.e., the creationof new roles and new workers). They also noted that changes may be facilitated byshifting the location of services from one setting to another or by integrating settingsand/or staff who work across settings. Irrespective of the strategy undertaken, anychange in skill-mix will require considerable education and attitude change.There are no guidelines as to how various disciplines might be involved in chronicdisease management. Both nurses and GPs bring both shared and unique knowledgeto the management of chronic diseases (Way, Jones, Baskerville & Busing, 2001). Inthis regard, Kernick (1999) described a commonly recognised conceptual continuum ofprimary care roles. At one end of this continuum, Auxiliary Nurses were responsible forsimple well-defined tasks such as dressings, specimen collection whereas traditionalPractice Nurses were responsible for treatment tasks such as minor injury managementand immunization. Extended Practice Nurses participated in protocol-directed clinical
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