Chronic disease is a massive problem that Australia is facing, and is challenging us to transform the way that healthcare is delivered. Every year, tens of thousands of Australians grapple with the serious, ongoing health problems of cardiovascular disease (CVD), diabetes, and chronic kidney disease (CKD), accounting for millions of hospitalisations and contributing to over half of all deaths.

Due to similar underlying risk factors and causes, these three diseases often occur concurrently, and their need for similar evidence-based treatments means that there is great potential for integrated models of care. Despite this, these three diseases are traditionally managed individually through separate specialist streams, even when patients have two or all three of these conditions. By both improving access to primary healthcare and integrating treatment for these three conditions, there is great potential to decrease the burden of these diseases on the healthcare system and to improve patient outcomes. Nurse practitioners (NPs – Masters-qualified clinicians with authorisation to practice autonomously, order and interpret diagnostic investigations, make referrals, and prescribe medications) are ideally placed to implement integrated chronic disease care.

Over the past two years, a novel, the integrated chronic disease NP clinic (the ICDNP) has been running on the south side of Brisbane for patients who have at least two of the above diagnoses. QUT researchers have been working alongside the NPs running this clinic to help to evaluate this new model of care. While the project is still running, results thus far indicate that this clinic is achieving its goals of decreasing health service utilisation and improving patient outcomes. Over the first two years, 74 patients were seen, and 544 occasions of service provided. Failure to attend appointments was very low, and patient-reported satisfaction with the clinic was overwhelmingly high. Achievement of blood pressure and pharmacotherapy targets was high, as was self-reported engagement in crucial at-home disease self-management behaviour. Over time, patient-reported utilisation of other health services has been decreasing, indicating that clinics such as these do indeed have the potential to decrease the burden on the healthcare system.

This ongoing project has the potential to be a considerable step forward in terms of healthcare reform. Our continuing, longitudinal research is providing evidence that the ICDNP improves access, efficiency, and patient outcomes while also decreasing the burden of these complex chronic diseases upon our already over-burdened hospital systems. We believe that this integrated model of care is replicable, and has the potential to contribute to a shift in the way that Australia cares for patients with multiple, serious chronic diseases.

Cassandra Stone
Nurse Practitioner – Nephrology (QUT NP Graduate)
Logan Hospital

Jennifer Abel
Nurse Practitioner – Diabetes
Logan Hospital

Maureen Barnes
Nurse Practitioner – Heart Failure
Logan Hospital

Professor Ann Bonner
Director of Research, School of Nursing, QUT
Chronic Conditions Management Program Lead, IHBI, QUT

Associate Professor Clint Douglas
School of Nursing, QUT

Kathryn Havas
School of Nursing, QUT

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