Talk Description
266Q - Research Paper
Abstract
Aim:
To implement a Nurse Navigator: Nurse Practitioner (NN:NP) led project to improve management of CKD at West Moreton Health Service (WMHS). The aim is to early review, risk factor management and intervention to slow disease progression through comprehensive assessment, education, lifestyle modifications, and supporting self-management.
Method:
NN: NP conceptual framework was developed and implemented as a practice guide to provide quality care for CKD patients either by face to face or through telehealth. Practitioners visited rural hospitals to scope, understand challenges and develop partnerships prior to commencement. Establishment of telenephrology clusters, according to patient’s demographic area to provide care closer to their homes. Commencement of NP led clinics to target “early CKD” patients. Navigation of patients with complex needs referred from inpatients, dialysis unit, outpatients, community, and other health services. Quantitative data was collected and analysed to measure the effectiveness of the project. Data is retrieved from databases such as WMHS Datahub, Nurse Navigator COMPASS, smart referrals and ieMR.
Results:
A total of 147 (NN), 128 (NP clinic) and 111 (telenephrology) patients were seen since 2019 through to Jan 2024. This includes 856 encounters as NN, (348 face to face and 508 phone calls) 352 as NP (F2F) and 491 at telenephrology clinics. Failed to attend rates have improved with 7.2% at telenephrology and 18.4% at NP clinics. Significant reduction noted in CKD waiting list, from 459 in 2021 to 93 in Jan 2024 despite the CKD population growth. Other benefits included less travel time and costs for patients and families, care closer home, better clinic attendance rate and improved health outcomes. 26 patients were discharged back to GPs for ongoing management as their risk factors had improved.
Conclusion:
The Role on NN:NP has improved patient outcomes for CKD patients and facilitated system improvement within the WMHHS.
Abstract
Aim:
To implement a Nurse Navigator: Nurse Practitioner (NN:NP) led project to improve management of CKD at West Moreton Health Service (WMHS). The aim is to early review, risk factor management and intervention to slow disease progression through comprehensive assessment, education, lifestyle modifications, and supporting self-management.
Method:
NN: NP conceptual framework was developed and implemented as a practice guide to provide quality care for CKD patients either by face to face or through telehealth. Practitioners visited rural hospitals to scope, understand challenges and develop partnerships prior to commencement. Establishment of telenephrology clusters, according to patient’s demographic area to provide care closer to their homes. Commencement of NP led clinics to target “early CKD” patients. Navigation of patients with complex needs referred from inpatients, dialysis unit, outpatients, community, and other health services. Quantitative data was collected and analysed to measure the effectiveness of the project. Data is retrieved from databases such as WMHS Datahub, Nurse Navigator COMPASS, smart referrals and ieMR.
Results:
A total of 147 (NN), 128 (NP clinic) and 111 (telenephrology) patients were seen since 2019 through to Jan 2024. This includes 856 encounters as NN, (348 face to face and 508 phone calls) 352 as NP (F2F) and 491 at telenephrology clinics. Failed to attend rates have improved with 7.2% at telenephrology and 18.4% at NP clinics. Significant reduction noted in CKD waiting list, from 459 in 2021 to 93 in Jan 2024 despite the CKD population growth. Other benefits included less travel time and costs for patients and families, care closer home, better clinic attendance rate and improved health outcomes. 26 patients were discharged back to GPs for ongoing management as their risk factors had improved.
Conclusion:
The Role on NN:NP has improved patient outcomes for CKD patients and facilitated system improvement within the WMHHS.