Continuity of care for people with multimorbidity: The development of a model for a nurse-led care coordination service
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Date
2020
Authors
Davis, K.M.
Eckert, M.C.
Hutchinson, A.
Harmon, J.
Sharplin, G.
Shakib, S.
Caughey, G.E.
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Journal article
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Australian Journal of Advanced Nursing, 2020; 37(4):7-19
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Abstract
Objective: To collaboratively develop a model of nurse-led care, within a multidisciplinary team and support continuity of care at the primary–secondary interface for people with multimorbidity. Background: Existing models of care are frequently based on a medical model, designed to manage a single disease condition, and thus pose a significant challenge to provide healthcare for people with multimorbidity. Particular design elements for models of care affecting the primary–secondary interface have been previously demonstrated, however,these have not been applied to the development of a nurse-led model of care for people with multimorbidity. Study design and methods: This paper, the first in a series of two, is part of a broader action research study and reports on the development of a model which will subsequently be assessed in terms of feasibility to provide a nurse-led care coordination service for people with multi-morbidity.This paper reports on the first action research cycle and methodology including a literature search, stakeholder engagement forums, validation workshop, team meetings, and professional engagement and validation.Results: Data from two stakeholder forums were sorted into 257 ‘structure, process and outcome’ statements and 86 goal related statements.These were cross referenced with design elements on models of care from the literature and finally aggregated into themes. The aggregated themes were then integrated into a model of care for a nurse–led care coordination service. The model consists of an overarching component, 4 domains and 6 operational areas with underpinning criteria.
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Copyright 2020 Australian Nursing & Midwifery Federation