What is important to know about your service?
Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) have better outcomes if assisted to self-manage their condition avoiding unnecessary admissions. Empowerment of the patients has to begin in the inpatient setting, continue in the outpatient rehabilitation programs and into the community environment.
Traditionally separate teams operate in each space even though the patients move in and out of each space. The multidisciplinary cardiorespiratory team can organise and deliver person-centred care to the patient, no matter which setting, giving seamless, continuous care in the right place at the right time.
What organisational model do you use?
Integrated services delivered through a multidisciplinary team that transcends inpatient, outpatient and community health settings.
What is special about the way care is delivered that is valuable for others to know?
The multidisciplinary cardiorespiratory team (nurse practitioner, registered nurse, and physiotherapist) was developed with realigned existing full-time equivalent (FTE) staff and initiates a relationship with the patient in the inpatient setting and continues working with them through pulmonary rehabilitation and home visits. This affords seamless transitions in a patient’s journey.
The interdisciplinary nature of the team means that professional boundaries are blurred with shared skills, so the patient’s needs are met by an available member of the team and are not professional-dependent.
Patients are referred to the team via the Electronic Medical Record, general practitioners or self-referral. Team members also visit the wards frequently to model and break down barriers between the different settings of acute and ambulatory, and primary care.
Companion documents describes options for organisational models in COPD and CHF. One option is the integration of services – this vignette describes the model from a local perspective.
How does it make a difference?
The team grew out of the recognition that, to a patient, health is one space whether it be inpatient, outpatient or community and the patient does not change, just the setting. That is one patient, one setting. The CardioRespiratory team’s concept is that the team is with the patient throughout their journey, on subsequent encounters and even through to the end of life, illustrated by the families.
What tips do you have for others?
- This model is sustainable and scalable in that no new FTE was required. It has also proved to be not person-dependent.
- Establish partnerships with non-government providers.
- The mindset that the setting is of secondary importance is fundamental, regardless of where the patient is in their journey.