Abstract:
Aim To evaluate a collaborative model that integrates secondary care support into general practice, targeting the main health problems of patients with long-term conditions. Methods The model was tested in two general practices in an area of high deprivation. Eligible patients were high users of the Middlemore Hospital Adult Medical Service. Model elements included nurse home visiting, record review, interprofessional case conference, and assertive follow-up and intervention. Data were collected from clinical records and interviews with patients and clinicians. Interviews were analysed using a general inductive approach. Results Record review and home visiting uncovered clinical and social information buried in the ‘systems records’ or unknown. Inter-professional case conferences resulted in prioritising interventions before assigning to practitioners for follow-up. Home visiting led to advocacy for social services, not possible in earlier general practice or emergency department (ED) consultations. Specialist hospital physician support in accessing hospital services strengthened the relationship with general practice. Case finding was an unexpected outcome of home visiting with individuals from the same household as the index patient assisted to access services. Conclusion All model elements—nurse home visiting, record review, interprofessional case conference, and assertive follow-up and intervention—were essential to resolving problems seriously impacting health status.
