Nurse practitioner community collaborative service
Aims of the NP role and model of care are to:
- Improve access to primary care services for community dwellers and residents of RACFs where there is currently limited capacity;
- Improve access to wound care and aged care specialist services for community dwellers and residents of RACFs;
- Improve communication and coordination of care between primary care providers and specialist services; and
- Improve education and support for RACF staff and other stakeholders, such as GPs, community nurses, allied health professionals and pharmacists in the areas of wound care, falls assessment, catheter and PEG care, end of life care, and management of minor injuries.
The NP works collaboratively by liaising with
- patients and their families
- allied health professionals
- General Practitioners
- Community Nurses
- Aged care service providers.
NPs are responsible for a complete and holistic episode of care. A complete episode of care may encompass
- comprehensive and/or targeted assessment
- requesting of diagnostics
- treatment/management care plans
- coordinated/case management implementations
- risk management strategies
- evaluation and discharge.
The service includes 3 clinical arms:
The Reactive Service
The Reactive arm of the service aims to provide an alternative to presenting to the Emergency Department for some community dwellers and residents of Residential Aged Care Facilities (RACFS). The service provides assessment and management of acute conditions and injuries that would otherwise result in an unnecessary presentation to hospital for those patients who are NOT able to be reviewed by their Primary General Practitioner assessment, health assessment, management plan, cognitive assessment or dementia diagnosis will be eligible for referral.
The Proactive Service
The Proactive arm of the service aims to promote health capacity and literacy, and provide a multidisciplinary service to community dwellers and residents of RACFs to assist residents to remain in their own environment for as long as possible. Patients who are in need of chronic disease management, aged care.
The Review Service
The Review arm of the service aims to provide post-acute review services for patients discharged from the ED; requiring clinical review within 24-48 hours of their discharge; and who are NOT able to be reviewed by their Primary GP. This service will be provided both as in-reach and clinic based.
Nurse Practitioner Community Model of care
The service will also provide weight loss programs as part of the multidisciplinary team. This model of collaboration and rapid response has the ability to not only improve access to primary health care for older people in both the community and RACFs, but also to prevent unnecessary hospital presentations through education of staff to recognize early clinical indicators and manage some acute medical conditions in the facility/home environment.
Referrals are received via a central point of intake
- from the hospital
- Ambulance Tasmania
- GP, Afterhours Call Centre
- Medical Specialist
- Patient / relative / carer
Referrals will be received and triaged by the NP according to clinical urgency, with the aim for the patient to be seen
Reactive within 2-4 hours after referral is received
Review within 24-48 hours for patients referrals
Proactive within <7 days
The NP will arrange to assess the patient or advise transfer to hospital as deemed appropriate. The patient assessment is made in collaboration with the Primary GP, and in discussion with the patient, family, and/or RACF staff.
Find us at two convenient locations:
Your Health Hub
Level 3, 31 Cambridge Road
Bellerive Quay TAS 7018
p: 6122 0150
f: 6122 0169
All Round Health and Community Care
Level 1 94 Liverpool Street
Hobart TAS 7000
p: 1300 309 599