This week as part of Nursing in the Community Week, we celebrate our community nurses, who give special meaning to the phrase “frontline heroes”.
Community nursing is a very broad description of many roles undertaken by nurses outside of the hospital setting. “The work community nurses do is not unlike the work of nurses in a ward; it includes highly technical procedures such as those done by nurses in Hospital In The Home (HITH) program or in Wound Clinic, and expert assessments such as those done by Clinical Nurse Consultants working in the Hospital Admission Risk Program (HARP),” says Johanna Hayes, Operations Director, Community Programs.
HARP provides services for people with chronic diseases and complex needs who need assistance with keeping safe and well at home. Specifically, they look at patients with chronic cardiac disease, chronic respiratory disease, diabetes, older patients with complex needs and patients with complex psychosocial needs or dementia.
The HARP team includes a specialist team of highly skilled care-coordinators from Nursing and Occupational Therapy backgrounds, Heart Failure and Respiratory Clinical Nurse Consultants, Physiotherapists, Social Workers, Geriatricians, Psychologists, Diabetes Nurse Educators and a Health Coach.
Julie Tran, Registered Nurse Care Coordinator HARP, says the program, “Provides disease specific education, care coordination, health coaching, allied health therapies and medical review.”
The program involves the patient, their carer, their GP, hospital staff and other community organisations to develop and implement a care plan that maximises health outcomes, maintains the person in their residence of choice and reduces preventable hospital admissions.
Recent data has shown that as a result of the HARP program, unplanned admissions had been reduced by 69 per cent and, in a 6 month period post-intervention, hospital admissions in these patients reduced by 54 per cent.
Julie says her move to community nursing was prompted “after working in the emergency department for a number of years and seeing first-hand the complex medical and social issues that lead to hospital presentations.”
Julie says each client is unique and the issues that arise are varied. “Prior to COVID-19, my day consisted of phone calls and home visits, during which I could monitor chronic disease management and provide education, liaise with local GPs and other health professionals, speak with and organise community support services, and ultimately advocate for the holistic needs of the client.”
“My day looks a bit different during COVID-19 as home visits require more planning and clients become more vulnerable due to social isolation, financial stressors and lockdown restrictions,” says Julie.
“Despite this, the HARP goals remain the same: helping clients to meet their physical, social and emotional needs in order to prevent avoidable hospital admissions,” she adds.
“Working in community nursing is a great way to practice holistic, person-centred care,” says Anne Marie Fabri, Associate Director, Community Programs.
“Working in someone’s own home, with their family or supports around them, helps remind us that our patients are people, members of their own community, and that we need to work with them to meet their goals,” she says.
Julie agrees. “I really enjoy community nursing because of the opportunities to develop positive health care relationships with clients. The barriers to building rapport in the acute hospital setting have less impact in the community, as we are now in their environment and we have more time to listen to their needs.”
“Ultimately, a simple phone call or a home visit is appreciated by our clients and personally rewarding for me,” says Julie.
Featured image shows Julina Shariff, another member of the HARP team, pictured with her client Andrew Carrigan. Says Andrew, “Julina did everything for me. I can’t thank her enough. She deserves a medal!”