Remodeling chronic disease management in general practice in the context of cognitive impairment.

Abstract

Background

Australian and international literature describe a significant service gap in dementia care provided in primary practice. In 2016, Ballarat Community Health received funds from the Commonwealth Department of Health, Nursing in Primary Health Care Program to develop a dementia care nurse-led clinic.

Objectives/Aims

To develop a clinic operated by a Practice Nurse (PN) with advanced dementia care experience to work with people with cognitive impairment (CI) and their carer using a specifically designed cognitive care pathway and chronic disease management (CDM) framework.

Method

A Plan-Do-Study-Act methodology was used to develop the clinic. This iterative process suited the evolving experiential nature of the project.

Results

During its development it was realised that the proposed model, a discrete service with separate care planning tools for people identified with CI was flawed as one of the reasons for poor dementia care outcomes in primary care is that people with CI are often not identified. Managing CI and dementia is inclusive of supporting health and well-being and to treat this group separately was to add to the stigma and marginalisation experienced by people living with dementia. Conversations about cognition need to be normalised within a CDM framework so people feel able to speak up about any concerns and feel confident that their primary health care team can support them. Dementia does not exist in isolation of other chronic disease and appropriate and effective CDM must be considered in context of the CI.

Implications/Outcomes for Planned Research Project

A PN model of dementia care which comprises a care planning pathway and on-line resource (embedded in the Dementia Pathways Tool) for PNs to support CDM with people living with dementia was developed within a clinic setting and with input from GPs and PNs. It is now being tested for its value and useability with PNs across Western Victoria. Initial results indicate that PNs perceive having this this model of care increases their likelihood of asking people about cognition and confidence in caring for people living with dementia.