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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:
She has had frequent hospital admissions related to left ventricle function, unstable angina and injuries. The patient goals are to:
The GP aims and goals are to:
The main risks are:
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 practice nurse is involved in day-to-day management under CVC funding.
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.
CVC enables an individualised and high-quality (bespoke) plan by acknowledging several factors that enable this type of more detailed and dynamically responsive care.
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:
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.
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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