Lea Davidson has been a registered nurse since 1999, has a bachelor of science degree in Health Studies and a post graduate certificate in Chronic Condition Management. Lea trained in the UK and worked in cardiology at a tertiary centre in Leeds, before becoming a community heart failure nurse specialist and independent nurse prescriber. In 2007 she moved to Alice Springs in the Northern Territory and has worked in primary and secondary care roles, both urban and remote. This year, Lea was awarded the NT Nurse of the Year Award for Excellence in Hospital Care for her current role of Clinical Nurse Consultant at Alice Springs Hospital. The role provides care coordination and self-management support to a vulnerable population with complex co-morbidities and a high readmission rate. ABSTRACT Background Issues Care coordination has been shown to be of most value when targeted at reducing avoidable hospital admissions, particularly for those with chronic conditions. There is evidence that under-coordination has a significant effect on vulnerable population groups, both within hospital and at the primary/secondary care interface. Issues such as intergenerational poverty, diverse health models and languages (within Central Australia), combined with geographical remoteness, high staff turnover and professional silos create a complex system; difficult to navigate for both patients and health professionals. Methods At Alice Springs Hospital (ASH) a Clinical Nurse Consultant for Preventable Chronic Disease provides care coordination for people with complex co-morbidities and a high readmission rate. The service aims to improve intra hospital continuity of care, facilitate multidisciplinary referrals based on patient priorities, provide self-management support and improve transfer of care. The service is available to all patients aged 15 and over with 5 or more admissions in the previous calendar year. Discussion The care coordination service at ASH is patient centred, with priorities for self-management support (SMS) identified by the patient themselves. As per the WHO (2002) Innovative Care for Chronic Conditions report, the model acknowledges the path from poverty to chronic conditions and vice versa; identifying what occurs at the micro, meso and macro-level of service. At the micro-level patients are encouraged to tell their story; identifying current self-management strategies and opportunities for support through quality interactions and collaboration. At the meso-level, some patients are referred to services which can provide ongoing SMS and proactive care coordination, which incorporates secondary prevention and access to community services. In Central Australia there are extremely limited services which provide this model of care and funding agreements place restrictions on referral criteria. The macro-level is where the greatest challenges for care coordination are faced. The overall policy and focus for healthcare remains episodic, reactive, disease and acute care focused with limited intersectoral collaboration. Conclusion The main barriers to effective self-management within this vulnerable group have been identified as homelessness, poverty, language, transport and feelings of disempowerment. The main barriers to effective self-management support are gaps in appropriate service, high staff turnover and continued focus on episodic acute care. Supporting those living with chronic conditions in Central Australia requires effective care coordination which is patient centred and addresses the complexity of a remote setting. |
