Within the Emergency Department (ED) at Monash Medical Centre, a team of community-based Nurse Practitioners and Senior Medical Consultants have created a powerful partnership and new pathway of care for patients with chronic conditions to receive care at home.
Announced as a finalist in the Celebrating Innovation in Healthcare category at the Victorian Public Healthcare Awards, the team have been recognised for their work diverting over 1,700 patients to community-based interventions and significantly improving patient experience.
Reducing the burden on acute services
Community-based chronic disease Nurse Practitioners have been embedded into the ED team and alongside Senior Medical Consultants have established an initiative to review and engage patients in the option to receive safe care at home – with fantastic results.
Aligned to our organisational priority of Excellence in Timely Care, objectives of the initiative include reducing acute hospital readmissions for heart failure, improving patient flow, and ensuring follow-up within 24 hours of discharge.
Through co-design workshops with consumers, our people, and community health representatives, this new project has been brought to life.
For one 63-year-old patient, it has been profoundly effective.
Recently diagnosed with heart failure, she presented in ED with bilateral leg oedema. With reassurance and her needs fully assessed, she agreed to be supported at home by the Heart Failure team who would visit her the next day and thereafter as she recovered.
Having initially been uncertain about leaving hospital, in her feedback survey the patient expressed gratitude for the support of the team. She described the initiative as the perfect solution for those who didn’t require hospitalisation, but, like herself, lacked confidence in managing their condition at home.Since May 2022, 1,740 patients have been successfully diverted to community-based interventions – improving patient flow and reducing pressure on the emergency department. Heart failure patients moved to community care have shown significant reductions in representation rates.
“I am delighted and incredibly proud that the team has been chosen as a finalist at the Victorian Public Healthcare Awards,” said Julie White, Director of Community Assessment and Response Team and Director of Nursing, Public Health and Community Division.
“The Community Nurse Practitioners in the Emergency Department play a vital role in connecting patients to ongoing community care and support. It’s all about working in teams to coordinate a journey, ensuring patients receive personalised, integrated care. Caring for clients in their homes is a privilege, and their feedback has been extremely positive.”
Monash Health has invested in placing Nurse Practitioners in the community setting, and there are plans to replicate the service within other emergency departments.
The project featured in a recent Safer Care Victoria (SVC) statewide forum as a best practice example of innovation and SCV are exploring funding expansion for this model across the State.
The Victorian Public Healthcare Award winners will be announced on 16 November 2023.
From all at Monash Health, congratulations to the entire team. Very best of luck!
