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Development, implementation and evaluation of nurse-led integrated, person-centred care with long-term conditions

Clare Lynette Harvey (School of Nursing, Midwifery and Social Sciences, Central Queensland University – Mackay Campus, Mackay, Australia) (Department of Educations, Humanities and Health Science, Eastern Institute of Technology, Taradale, New Zealand)
Jonathan Sibley (School of Business, Eastern Institute of Technology, Taradale, New Zealand)
Janine Palmer (Renal Service, Hawkes Bay District Health Board, Hastings, New Zealand)
Andrew Phillips (Allied Health, Hawkes Bay District Health Board, Hastings, New Zealand)
Eileen Willis (Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia)
Robert Marshall (Department of Education, Humanities and Health Science, Eastern Institute of Technology, Taradale, New Zealand)
Shona Thompson (Allied Health, Hawkes Bay District Health Board, Hastings, New Zealand)
Susanne Ward (Respiratory Department, Hawkes Bay District Health Board, Hastings, New Zealand)
Rachel Forrest (Department of Education, Humanities and Health Science, Eastern Institute of Technology, Taradale, New Zealand)
Maria Pearson (Department of Education, Humanities and Health Science, Eastern Institute of Technology, Taradale, New Zealand)

Journal of Integrated Care

ISSN: 1476-9018

Article publication date: 3 July 2017

Abstract

Purpose

The purpose of this paper is to outline a conceptual plan for innovative, integrated care designed for people living with long-term conditions (LTCs).

Design/methodology/approach

The conceptual plan delivers a partnership between the health system, the person with LTCs (chronic), their family, and the community. The partnership aims to support people at home with access to effective treatment, consistent with the New Zealand Government Health Strategy. This concept of people-owned care is provided by nurses with advanced practice skills, who coordinate care across services, locations and multiple LTCs.

Findings

With the global increase in numbers of people with multiple chronic conditions, health services are challenged to deliver good outcomes and experience. This model aims to demonstrate the effective use of healthcare resources by supporting people living with a chronic condition, to increase their self-efficacy and resilience in accordance with personal, cultural and social circumstance. The aim is to have a model of care that is replicable and transferable across a range of health services.

Social implications

People living with chronic conditions can be empowered to manage their health and well-being, whilst having access to nurse-led care appropriate to individual needs.

Originality/value

Although there are examples of case management and nurse-led coordination, this model is novel in that it combines a liaison nursing role that works in partnership with patients, whilst ensuring that care across a number of primary and secondary care services is truly integrated and not simply interfaced.

Keywords

Citation

Harvey, C.L., Sibley, J., Palmer, J., Phillips, A., Willis, E., Marshall, R., Thompson, S., Ward, S., Forrest, R. and Pearson, M. (2017), "Development, implementation and evaluation of nurse-led integrated, person-centred care with long-term conditions", Journal of Integrated Care, Vol. 25 No. 3, pp. 186-195. https://doi.org/10.1108/JICA-01-2017-0003

Publisher

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Emerald Publishing Limited

Copyright © 2017, Emerald Publishing Limited