Development, implementation and evaluation of nurse-led integrated, person-centred care with long-term conditions

Abstract

Purpose The purpose of this paper is to outline a conceptual plan for innovative, integrated care designed for people living with long-term conditions (LTCs). Design/methodology/approach The conceptual plan delivers a partnership between the health system, the person with LTCs (chronic), their family, and the community. The partnership aims to support people at home with access to effective treatment, consistent with the New Zealand Government Health Strategy. This concept of people-owned care is provided by nurses with advanced practice skills, who coordinate care across services, locations and multiple LTCs. Findings With the global increase in numbers of people with multiple chronic conditions, health services are challenged to deliver good outcomes and experience. This model aims to demonstrate the effective use of healthcare resources by supporting people living with a chronic condition, to increase their self-efficacy and resilience in accordance with personal, cultural and social circumstance. The aim is to have a model of care that is replicable and transferable across a range of health services. Social implications People living with chronic conditions can be empowered to manage their health and well-being, whilst having access to nurse-led care appropriate to individual needs. Originality/value Although there are examples of case management and nurse-led coordination, this model is novel in that it combines a liaison nursing role that works in partnership with patients, whilst ensuring that care across a number of primary and secondary care services is truly integrated and not simply interfaced.

Case study of home care for isolated and frail elderly patients by general practice nurses

“…Such "enhanced confidence" in new roles (Workman and Pickard (2008), and "nurse leadership authenticity" empowering decisions, were also noted by Wigens (2016). Other examples of a similar central role are described by Harvey (2017) in Queensland, where they developed, implemented and evaluated "nurse-led integrated person-centred care with long-term conditions".…”

Person-centred rhetoric in chronic care: a review of health policies

“…The NN program is well suited to bring about PCC in an environment where the tensions created by a disease-centred approach and the systematic barriers are present. Nurse navigators do not remove the responsibility of the specialist team but rather bring together numerous clinicians to pay attention to the needs of the patient as an individual (Owczarzack et al, 2016;Harvey et al, 2017). During the pilot stage of the specific navigator program of Queensland, NNs were found to assist in streamlining care while also developing a relationship with the patient that increased the supporting mechanisms including valuing, improving health literacy and patient coping skills (Spooner et al, 2018).…”

“…In the traditional biomedical model, each health condition is monitored and managed in isolation by different specialists. Using this model to manage multimorbidity carries the risk of miscommunication during care planning and fragmentation of care as patients go from one specialist to another (Stokes et al, 2017;Moffat and Mercer, 2015;WHO, 2016;Harvey et al, 2017). From the patients' perspectives, involvement of multiple specialist services often means multiple appointments in geographically diverse areas that can be difficult to attend.…”

The evaluation of nurse navigators in chronic and complex care

“…The research framework for this evaluation is based on a successful pilot study of a nurse‐led chronic respiratory programme conducted in one region now employing navigators (Harvey, Buckley, & Scott‐Chapman, ; Harvey et al, ). The pilot study demonstrated individualized care managed in the community could be achieved within existing budgets.…”