HOW IT WORKS
This initiative is built around an investment in training advanced practice nurses (APNs) to work closely with patients and general practitioners (GPs) in providing evidenced-based care for chronic conditions like diabetes. APNs support clinical care by updating electronic patient medical records, introducing electronic prompts and reminders, and providing clinical services such as eye and foot exams. They facilitate shared patient-provider decision-making, including the identification of goals for care and development of individualized care planning. APNs also identify specific conditions that are priorities for self-management and provide patients with specific self-management tools. Program enrollment is based on specific clinical characteristics. A sophisticated information system infrastructure supports the program and its recruitment process.
ASALEE has grown steadily since its launch in 2004 in one county council and three practices. By 2011, it had expanded to four regions and 50 practices, and by 2017 it expanded to a national level at more than 700 practices. An extensive evaluation that is currently underway is using a mixed-method design to examine a wide range of process and outcome measures.
APNs serve as a new resource for clinical practices and GPs. They are trained to work directly with the GP to support a range of quality improvement initiatives around the management of chronic conditions. The APN makes extensive use of the data infrastructure to monitor care and provide reminders to GPs. The APN also provides clinical screening and support to patients.
Patients with multiple chronic conditions continue to receive care from their GP but are also examined and counseled by an APN, who involves patients and caregivers in care decisions. Patients and their caregivers are given counseling on care self-management and lifestyle changes so that patients are empowered to take control of their health.
One key to the program is the training and day-to-day support of APNs. Training and support is provided through a non-profit organization which works with clinical practices using APNs. The standardized, comprehensive training protocol includes three days dedicated to teamwork protocols, six days for patient education, and three days of on-site follow-up by another APN.
Central government funding supports the training program and the APN in the practice setting. There is lump-sum funding which supports ASALEE’s APNs who are provided to a set of clinical practices. Individual GPs receive supplementary payments for coordinating care with the APN. There is also an in-kind transfer to the practice, because the APNs’ salary is supported by ASALEE through public funding, not the practice’s usual revenue flow.