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Introduction
This paper outlines a conceptual framework for the development, implementation and evaluation of an integrated model of care for people living with long-term conditions (LTCs) in New Zealand (NZ). It utilises an appropriately prepared Liaison Nurse Consultant (LNC) coordinating care across primary and secondary services involved with managing chronic conditions, alongside the augmentation of patient autonomy- and community-inclusive collaboration. The model requires strengthened linkages between the person living with LTCs and their family, the community, primary services and acute care services. It addresses culturally competent care, drawing on the principles outlined by the NZ Māori Health Strategy and the NZ Health Strategy (Ministry of Health, 2014, 2016). This nurse-led model is informed by the Icelandic Nuka Health System, and the philosophies of equity-driven care (Browne et al., 2012; Chow and Wong, 2014; Gottlieb, 2013). Our point of difference is that it combines patient autonomy (as different from patient-centred care), with equity, alongside the concepts of integrative care that requires the interfacing of health and social services. The focus of the LNC is crucial in the first month after any change or exacerbation of an illness. This is particularly so for newly diagnosed patients, when typically, care plans and medications are either introduced or altered, and during which time patients are at their most vulnerable in terms of understanding and implementing these changes at home (Harvey, Buckley and Scott-Chapman, 2015; Jatrana and Crampton, 2009). The expected benefit is to have people living with LTCs to effectively manage their health and well-being through self-management and ownership of their illness, with healthcare services partnering with them and their family. Whilst it is anticipated that most patients will self-manage following an initial change in plan, the LNC will case manage those who are unstable or complex, and who are known to be frequent attenders to the emergency department or in-patient setting. This aspect will be guided by a Care and Triage Toolkit to be developed during this study, informed by existing models of chronic care, equity in care and primary care assessment (Carswell, 2015; California Quality Collaborative, 2012; Browne et al., 2012; Gottlieb, 2013).
Background
It is well known that people with a chronic illness often experience lack of coordinated care as they negotiate their journey...