Role of the GP liaison nurse in a community health program to improve integration and coordination of services for the chronically ill

Abstract

This paper explores the role of the General Practitioner Liaison Nurse (GPLN) in improving integration and coordination of services within Primary Health Care. This position can play a major role in care coordination and cultural change. The GPLN within HealthOne Mt Druitt (HOMD) identifies patients' needs and facilitates communication, case conferencing and care coordination between health and other providers. The priority areas of children and their families at risk or with significant unmet needs, and chronic aged and complex care, were identified as target areas. This paper focuses on the GPLN within the chronic aged and complex care service model. The GPLN within HOMD was able to improve coordination and integration of services for patients of the facility. Activities included organising multidisciplinary services and addressing psychosocial issues. Patients and community health staff identified the importance of the role for improving coordination and integration of services. Decision and policy makers saw the position as vital to the implementation, operation and sustainability of HOMD.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…Causal link 3:10 -care planning and boundary spanning Nine studies 21,66,68,78,83,90,91,93,94 provided further evidence that boundary-spanning roles facilitated many forms of care 'integration'. These roles may be filled by care co-ordinators, nurse practitioners, CHWs and many other occupations.…”

“…Although MDT members might see these roles as the 'glue' holding care co-ordination and care teams together, 90 interviews with 25 clinical pharmacists and 17 primary care clinicians found that traditional status hierarchies could be a barrier to effective collaboration and communication in PCMHs, where there were new roles for some or all professionals. 92 An online focus group of people self-identifying as care…”

“…These boundary-spanning roles improved co-ordination and integration of services through improving communication (formal and informal) between the various other care providers, through co-ordinating multiple services, addressing psychosocial as well as physical health issues, providing the conduit for GPs, community health, and other health and social care providers to work together more closely. 90 They also provided support for clinical and administrative staff. 87 MDTs are also part of the health-care delivery system redesign and connection to the community care resources involved in the CCM.…”

“…93 Similarly, policy-and decision-makers in a chronic aged and complex care network suggested that boundary-spanners need to have the seniority and expertise to be leaders who earn and maintain the respect of the MDT by initiating culture change, and to have sufficient flexibility in their role to work with GPs to support and add value to the care they provide. 90 …”

“…That gave users good overall care by a better team at lower cost, reduced GP workload and freed specialists to support more severe cases. 66 Causal link 3:10 -multidisciplinary teams produce care planning at the patient level Ten studies 21,66,68,76,78,83,90,91,93,94 suggested that MDT working facilitated care planning at the patient level through the operation of boundary-spanning roles and by giving greater access to enhanced primary care.…”