The solution A nurse-led service was set up to provide responsive, proactive patient centred care. Following a review of community based services, new pathways, policies and patient group directions were developed. The transfer of 1,686 patients into the primary care service was completed in September 2011 and the secondary care service was decommissioned.
Under the new nurse-led pathway, the team aims to give patients an appointment within one week of referral. Referrals are triaged by nurses and physiotherapists to ensure patients with inflammatory arthritis have rapid access to care.
Patients are reviewed every four to six weeks until the disease is well controlled. If the patient is stable for 12 months, they are placed on an annual review with access to the team via the advice line if needed. If the patient’s disease remains active despite optimal treatment, or if co-morbidities have been detected, the patient is reviewed by a consultant.
Close collaboration with other organisations and partnership working has proved key to promoting self-management.
Results Patients like the service – 95% are extremely likely or likely to recommend it to friends and family. Furthermore, in 2014, 95% of respondents were completely satisfied or satisfied with their care. In relation to shared decision making, 83% felt that their care was collaborative.
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