SPECIALIST NURSE SUPPORT IN PRIMARY CARE VUNERABLE POPULATIONS AND PALLIATIVE CARE Rachael Walker NP- Adult/Older Adult (Renal)

OVERVIEW Kidney Disease How this relates to palliative care and vulnerable populations Why integrate? The Model The Patients The Outcomes How could this model be used in Palliative Care?

ESKD Pt’s on dialysis – 15.4% die each year >75 years – 25% High CVD Risk High Symptom Burden Decreased quality of life

Slide courtesy of Dr. Kjellstrand BREAST CANCER HIV PROSTATE CANCER THE DEATH-RATE WAS THREE TIMES THAT OF BREAST CANCER AND HIV, TWICE THAT OF PROSTATE CANCER Slide courtesy of Dr. Kjellstrand Compare outcomes to something patient can relate too! Breast CA and Prostate CA. HEMO

VUNERABLE POPULATIONS Over 50 Maori Pacific Diabetes / Hypertension /Weight /Smoke Family History Less Access “Hard to Reach”

PREVENTION Prevention of ESKD is (FAR, FAR, FAR, FAR) better than …… Lets re-change our focus

WHY GO TO PRIMARY CARE? Integration Collaboration Removing Silo's Effective Communication Better, Sooner, More Convenient Care Up-skilling other staff Why not?

THE MODEL Secondary Care Nurse (Me) 2 Practices High Dep Areas Working together with Practice Nurses Identifying High Risk Patients Holistic Initial Assessment Intensive Management Continuity and Follow-Up

ENGAGEMENT Stakeholder Hui Practice Hui Invitation from GP Phone Call follow-up Practice Nurse Phone Call /Door knock - follow-up Specialist Nurse 1st Assessment – Primary Care or Home

THE PATIENTS High Risk Diabetic Hypertensive Albuminuria/Proteinuria At risk of /with CKD

THE DEMOGRAPHICS 71% Maori 19% Pacific 10% NZE Age 30-79 (>50% 50-65 yrs) 10/52 had eGFR< 45ml/min >50% HbA1c >10% (86mmol/mol) 90% Obese 75% High CVD Risk

INITIAL ASSESSMENT Assess knowledge Assess self-management & health literacy Assess current health Assess current lifestyle factors Clinical markers Physical Assessment Medication Review Develop Care Plan

SELF-MANAGEMENT Knowledge Involvement Care-Plan Monitor and Respond Impact Lifestyle Support

FLINDERS CHRONIC CONDITION PROGRAM

INTENSIVE MANAGEMENT PHASE Initial Plan 2 weekly reviews – Rapport & Trust Education – Talk properly Monitoring Support Reassess initial Plan Referrals –Dietician, Diabetes, Exercise, Counselling, Out-reach nurses, Other providers

FOLLOW-UP PHASE At 12 weeks Re-assess Are we at target Have we reached our goals More education Any other support Re-plan – 3 months / 1 month/ 2 weeks Rechecks/Re-establish Goals and Plan

HOW LONG FOR? 12 month Pilot Review formally 3 monthly Continue with Practice Nurse Patient Self-management –on-going

OUTCOMES Patient Whanau Practice Nurses GP’s Secondary Care

PATIENT Engagement Participation Better knowledge Able to understand Changes Lifestyle Changes

KNOWLEDGE CHANGE

LIFESTYLE CHANGE

CLINICAL CHANGES Statistically Significant Improvement in: ACR Systolic BP Diastolic BP HbA1c BMI Smoking Cessation Self Management

WHANAU Extra Recruits Screening and Awareness Lifestyle Changes Exercise Nutrition Awareness Knowledge – Shared

PRIMARY CARE Practice Nurses GP’s Knowledge Up-skilling Self-management GP’s Indirectly The Same Relationships /Open lines / Better communication

SECONDARY CARE Knowledge Up-skilling Awareness Relationships Open/lines/communication

HEALTH CARE DOLLAR $80,000 /ANNUM Hospital admissions Complications

THE MODEL Chronic Conditions Diabetes CVD Risk Hypertension

PALLIATIVE CARE? How could this model work for you?

WORKSHOP QUESTIONS Is this a role? If it’s a role – where does it sit?

How do you ensure leadership?

What is the role of specialist palliative care?

How do you promote integration?

Who will benefit most?

How will you know if inequalities have been reduced?