Role of the GP liaison nurse in a community health program to improve integration and coordination of services for the chronically ill

Abstract

This paper explores the role of the General Practitioner Liaison Nurse (GPLN) in improving integration and coordination of services within Primary Health Care. This position can play a major role in care coordination and cultural change. The GPLN within HealthOne Mt Druitt (HOMD) identifies patients’ needs and facilitates communication, case conferencing and care coordination between health and other providers. The priority areas of children and their families at risk or with significant unmet needs, and chronic aged and complex care, were identified as target areas. This paper focuses on the GPLN within the chronic aged and complex care service model. The GPLN within HOMD was able to improve coordination and integration of services for patients of the facility. Activities included organising multidisciplinary services and addressing psychosocial issues. Patients and community health staff identified the importance of the role for improving coordination and integration of services. Decision and policy makers saw the position as vital to the implementation, operation and sustainability of HOMD.