Collaborating to help patients with complex issues

A coordinated, team approach to care for an elderly patient with multiple comorbidities

Please refer to the disclaimer before reading the case studies.


The patient, female, aged 91 years, is a war widow living alone in a suburban area, with one son (aged in his 70s) living a 15-minute drive away. She has multiple comorbidities:

  • Vasculopathy (coronary artery bypass graft and small cerebrovascular accident)
  • Biventricular failure, well controlled on diurectic
  • Unstable angina
  • ‘Burnt out’ rheumatoid arthritis
  • Anxiety disorder / multiple phobias
  • Low BMI, frail, with falls risk and accidental injury risk both high
  • Multiple drug allergies / intolerances

She has had frequent hospital admissions related to left ventricle function, unstable angina and injuries. The patient goals are to:

  • Stay at home (when she is no longer able to go out for lunch) and die there
  • Not be a burden to her son
  • Avoid admission to two out of three local hospitals at all costs (she has a phobic reaction to two).

The GP aims and goals are to:

  • Allow the patient to stay in her own home as long as possible
  • Give her a sense of control over her healthcare transactions
  • Avoid identified risks

The main risks are:

  • Falls and injuries
  • Medication misadventure post-hospital admissions
  • Unavoidable nursing home admission.

Who helped the practice and you as a GP?

We looked at what the Coordinated Veterans’ Care (CVC) program offered. Strategies employed within the CVC program to manage risks and support patient goals:

  • The GP is supported to operate within a community team structure, independent of extended primary care (EPC) structures, and to do ‘non-face-to-face’ work/extended liaison.
  • The practice nurse role is able to expand and consolidate, evolving into a pivotal role, formalised in broad enablers (improved coordination and collaboration; better targeting of care and identification of barriers; improved ability of the practice nurse, the patient and the patient’s family to identify and manage issues as they arise; improved efficiency.)

The practice nurse is involved in day-to-day management under CVC funding.

What did you do to make it happen?

  • Drilling down – we wrote the above features into a CVC plan and reviewed this regularly to ensure implementation was happening as it should and to explore opportunities to expand.
  • We involved the practice nurse from the beginning.

The GP was supported to work within a team structure, especially before, during and after admissions to hospital. This overcame the barrier imposed by the descriptor around the use of EPC case conference items.

What specific strategies did you use?

  • Congestive cardiac failure (CCF) – early detection via phone of exacerbation of health problems, with added opportunity to conduct wider phone assessment as indicated.
  • Employed sick day management plan as required for the patient.
  • A shared plan around emergency admissions – we organised a direct link for the patient or son by mobile phone with the GP if an ambulance crew was attending. The GP would speak to the crew and emergency department (ED) at the only hospital accessible to the patient and arrange transfer (this was often critical, as private EDs are frequently ‘on bypass’ and crews are otherwise instructed to transport all patients to a public ED0. This strategy came into play about once yearly.
  • Advocacy and active contribution to management during hospital admission (eg GP successfully advocated to arrange blood transfusion prior to discharge after skin graft for shin wound, resulting in symptomatic improvement in CCF and [likely] accelerated healing).
  • Better clarification of roles and responsibilities.

CVC enables an individualised and high-quality (bespoke) plan by acknowledging several factors that enable this type of more detailed and dynamically responsive care.

What outcomes/improvements do you think you achieved?

  • Vastly enhanced patient confidence that her needs were being met
  • High-level support for son
  • Readmission avoidance
  • Tight medication control
  • Good time management (minimisation of wastage from poor communication)
  • Team satisfaction with results and a sense of cohesion

What made the most difference?

Communication made the biggest difference.

The involvement of the practice nurse in this new level of communication was paramount, with a move away from a narrow role of relaying messages and basic triage.

Central to this was the formalisation of this broader role of the practice nurse through the renaming of this role in the CVC descriptor. Our nurses were pleased to embrace this recognition.

Instead of having the practice nurse conduct a holistic health assessment once a year, this occurred on a continuous basis.

The program gave the practice nurse a sense of ownership and provided the practice nurse with an extra quarterly payment as a reward for extra effort.

Other advantages were in:

  • Talking through issues, conducting phone and onsite assessment, trouble shooting and safety netting;
  • Liaison with family, being able to include them in real-time decision-making.

What would you say to GPs who may consider doing similar things? What would you do differently?

Meet face-to-face more often with key community care team members for optimal shared understanding when a situation becomes critical (eg trying to avoid an admission).

For frail, elderly people with multimorbidity at home, the ground can shift in a 24 hour period.

Micromanagement is necessary to prevent deterioration in health status with ensuing hospital admissions or nursing home attendance.

Relationships are crucial to the success of these strategies – most older people cling to the advise of those, and only those, they trust. This is why they sometimes wait for their own physician to return from leave.

Enacting the detail of a care plan is important, with, for example, weekly phone-ins and maintaining a current weight or fluid chart.

A ‘hospital in the home’ set-up can be achieved in a limited fashion if parameters are clearly defined.

Twice-daily review for 2-3 days can be very effective. Geographic proximity is important.

You can keep someone at home with diarrhoea and heart failure for one night, but only if you can check on them the next day.

Liaison with a pharmacist is more vital than ever, with multitudes of brands of drugs and dwindling commitment to providing continuity of personnel or product. Frequent checking of packets for errors will help avoid medication misadventure.

Having a person stay at home sick rather than go to the hospital requires confidence in covering the dusk-to-dawn phase (eg ensuring the patient/carer has a number they can call if things go wrong).

In the case described, our patient required someone to direct the ambulance to the correct ED.

In terms of return on effort, do you think the whole process was worthwhile?

Very much so! Basically, this is how I was already operating didn’t feel like I could ask much of our practice nurse without dedicated funding.

The feedback from the patient and family was superb, and we even regularly heard second-hand from others (eg the ambulance service) about how well the system worked and how different it was from normal care.

Dr Christine Boyce, Hobart GP


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