Integrated chronic disease nurse practitioner(ICDNP) model of care: Improving the patient journey

Background Chronic kidney disease, cardiovascular disease and diabetes mellitus and are highly prevalent in Australia and there is a well-established association between these three diseases. In 2014 an Integrated Chronic Disease Nurse Practitioner (ICDNP) model commenced to provide streamlined care, improve access through a coordinated approach for patients with at least two of these three chronic diseases, and to improve the patient journey and quality of life. Aim To examine the perceptions of stakeholders following the introduction of the ICDNP clinic. Methods Using a qualitative descriptive design, 14 patient interviews and 3 focus groups with staff (medical, allied health, nursing and administrative) were conducted. Data was analysed for themes. Results Overall patients described the benefits of attending the clinic were due to the good communication and interaction with the nurse practitioners and how this contributed to building trust and enabling them to have a better understanding of their chronic diseases. Staff recognised the positive impact that the ICDNP clinic had on the patient’s navigation of the healthcare system, reducing the need for multiple clinic appointments, and how the clinic contributes to improving chronic disease self-management. Conclusion The ICDNP model of care has shown a high level of patient satisfaction with regard to their journey of chronic disease self-management. Importantly healthcare professionals are supportive and engaged with the clinic due to improved communication and collaboration across multiple specialties and relevant team members.