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Nurse-led care program proves valuable in South Gippsland

Throughout Gippsland, some small rural communities experience high rates of health disadvantage, combined with significant barriers to access care.

For these communities, barriers to accessing care relate to the limited or lack of non-urgent patient transport services. This can have a significant impact, particularly for older people and those with chronic complex health needs.

In early 2018, Gippsland Primary Health Network (PHN) was endorsed by Ambulance Victoria to implement a project where three general practices in South Gippsland were engaged to implement a trial nurse-led model of care and coordination.

This model of care identified moderate to high risk patients, assessing its effectiveness on the use of ambulance services and acute/tertiary health services.

Gippsland PHN identified Foster, Leongatha and Korumburra as the areas of focus, due to the population health profile of people aged 65 years and over with chronic and complex conditions, general practice capacity, competency and readiness to participate and alternative transport options to Ambulance Victoria.

As the project draws to a close, Gippsland PHN has found the general practice teams have worked collaboratively and increased patient empowerment to manage their own conditions appropriately, promoting integrated care and a more seamless patient journey for complex care patients.

These patients have frequent planned interactions with the primary and acute health systems however in the absence of local taxi and community transport systems, there has been a tendency in the past for them to use ambulance services.

While delivering the nurse-led model of care, general practices have held sociable hour appointments with clients with guidance on self-management principles. A template to guide the patient on when they should call 000 has been introduced. The use of the completed template will further streamline the patient journey and improve outcomes.

A nurse manager from one of the general practices participating in the project saw 40 patients supported during the project at her clinic. “The project has been extremely valuable in preventing unnecessary ambulance transfers and hospital admissions which are expensive, resource intensive and may include futile transfers to hospitals,” she said. Patients’ feedback confirmed they felt safe, cared for and more able to stay in their own home longer, prior to moving into permanent care. This was echoed by family members, some who cared for their relative at home.

Similar results were reported from all participating general practices.