Implementation of a collaborative community-based integrated model of care for patients with liver disease (focusing particularly on Hepatitis B and Hepatitis C) will be achieved by co-locating a specialist gastroenterologist and nurse practitioner in community general practices that have been identified to have high caseloads, and patients with culturally and linguistically diverse (CALD)/refugee backgrounds. Patients will be identified by General Practitioners (GP) and GP practice nurses.
The model of care will focus on:
- Population groups most at-risk of viral hepatitis with poor outcome potential, and,
- Those patients that are historically less engaged with tertiary level care.
A nurse practitioner will review the patients in the community followed by either a case-conference and /or in-person review by a liver specialist at the GP practice. Continuing care will occur in the community practice setting. For patients with advanced disease, supported referral to secondary services will be facilitated as appropriate. The model provides for capacity building by upskilling GPs, nurse practitioners, practice nurses and staff through learning and shared care and enhancing independence.
It expanded in operation to include a partnership with Inala Primary Care in the form of an Outreach Specialist Team.