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

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.