Background

Management of complex multiple chronic diseases is one of the biggest healthcare challenges today. In 2014 a novel community based integrated Nurse Practitioner (NP) clinic was commenced for patients with at least two chronic diseases including chronic kidney disease, diabetes or heart failure to reduce clinic waiting times, integrate care into one clinic appointment and reduce the confusion of advice from multiple healthcare providers. Patients receive comprehensive assessment and care plans, self-care education with exercise and lifestyle advice, medication review and adjustment and follow up appointments. Collaboration with General Practitioners and disease specific speciality teams occurs.

Aims

To examine the effect of an integrated NP clinic on health outcomes for people with chronic disease.

Method

A mixed method, longitudonal evaluation of the clinic is currently in progress. To illuminate the contribution of NP's, two complex patient case studies drawing from clinical and patient reported outcomes data will be presented.

Findings

Both patients had multiple chronic diseases which complicated the management of each individual illness. At baseline, both patients had good knowledge of heart failure and indicated a reasonable level of confidence in their ability to self-manage their condition, but neither were achieving HbA1c targets (10.8% and 14.1%) and overall had low quality of life. Adding a diabetes NP into both patients management helpd reduce HbA1c and weight. Due to the integrated care provided, renal function stabilised and there was some reduction in BMI. Blood pressure remained within targets (130/80) and patients reported high levels of satisfaction with the care provided.

Implications

People with diabetes frequently have cardiovascular disease and reduced kidney function making management increasingly complex. This is particularly the situation when speciality teams focus only on one disease. In this clinic, NP's collaborate and provide holistic care improving outcomes and quality of life for those with multiple co-morbidities.