Next Practice Deakin

A case study in multidisciplinary team-based care 

by Melanie Irwin, Primary Times Managing Editor 

Source: APNA Primary Times Summer 2024-5

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Canberra clinic Next Practice Deakin is leading the way when it comes to multidisciplinary team-based care. With a large team of healthcare professionals, including several nurses and nurse practitioners (NPs), the practice cares for patients of all ages. I caught up with the nursing team to hear about how they collaborate to provide comprehensive individualised care. 

Next Practice Deakin is a general practice clinic that opened in Canberra in 2021. The practice is staffed by a large multidisciplinary team that includes GPs, NPs, nurses, a geriatrician, a social worker, a pharmacist, a dietitian, an exercise physiologist, a physiotherapist and a dental hygienist. It offers a blended model of care that includes face-to-face consults, home visits and telehealth. 

The nursing team at Next Practice Deakin consists of seven NPs, three registered nurses (RNs) and one enrolled nurse. Each team member contributes unique capabilities. For example, different NPs specialise in different diseases and conditions: Liz Obersteller is a Credentialled Diabetes Educator, Anna Buenaseda specialises in chronic cardiac and respiratory diseases and Danielle Kenndey specialises in dementia care. 

‘I’m a generalist nurse practitioner,’ says Diane Bowden. ‘I was a practice nurse for 15 years, so when I did my NP training, I did it all through general practice, so that makes me a general practice nurse practitioner.’ 

Macy Pamuspusan is an RN and the practice’s lead nurse. ‘Macy is one of our foundational pillars in keeping everything running!’ says Ruth Spencer, another RN with many years of experience in general practice. 

The whole team benefits from the combined set of capabilities. The specialist skills and knowledge of the more experienced nurses is transferred directly to the other team members in their day-to-day collaboration and this results in efficient and comprehensive care for patients. 

The patient cohort 

Homebound Care 

The practice has a focus on aged care and disability care. Many of the nursing staff visit patients at home as part of the Homebound Care program, which has about 100 patients, many of whom are on the National Disability Insurance Scheme (NDIS). 

‘Homebound Care is for people who have difficulty attending appointments in a normal GP setting,’ says RN Jo O'Brien. ‘This might be for physical or psychosocial reasons. Our social worker will often get involved. This is very important to the care we provide. We might also make referrals to our allied health team. We have a physio, an exercise physiologist and we’ll also be getting a psychologist. 

‘Our NDIS patients range in age from teenagers to those in their sixties. These patients have complex care needs and require frequent contact. This could include medication administration or coordination of other types of care, or helping them make and attend appointments.’  

Residential aged care 

The practice provides care for most of the residential aged care facilities around Canberra, with more than 900 aged care residents on the books. Most of the nursing team visit the facilities regularly and see the residents face to face. This care includes check-ups, vaccination clinics and various other procedures. 

LDK is a seniors’ living community in Canberra where residents have their own apartments and care is provided according to their needs. Ruth, Macy, Jo and enrolled nurse Sushma Gurung are responsible for creating comprehensive healthcare plans for residents, which they share with the care managers at LDK. This includes their physical and psychosocial healthcare needs.  

‘We pay attention to their behaviour,’ says Ruth. ‘We might identify changes in mood or cognition, and then we coordinate the appropriate care. The primary person is always the patient. We focus on developing the care that that patient needs.’ 

Patients of all ages 

‘We look after people over the whole life span,’ says Liz. ‘This includes well women’s checks, we coordinate care for babies and new mothers, immunisations, right through to palliative care. It’s the whole life journey. 

‘We aim to provide individualised care. We do wounds, we do skin checks. We’re always on the lookout for signs that a person may need special or preventive care. And our patients are diverse. We have a small Indigenous community that we care for. Many of our patients speak English as a second language. Our patients’ cultural wellbeing is very important. We include that in our health assessments.’ 

A team effort 

A large multidisciplinary team means that expert advice is readily available when needed. NPs Anna, Danielle and Liz are on call when other team members need their specialist decision-making, and the practice embraces the latest technology to facilitate real-time remote collaboration. 

‘Our TytoCare machine enables live remote reviews between our nurses and nurse practitioners,’ Macy explains. ‘We can do assessments with patients remotely. Anna uses it a lot to listen to patients’ lungs and hearts remotely.’ 

The device enables carers to send health data in real time, which eliminates the wait times they’d experience with phone calls.  

‘We’re looking at different ways to include remote patient monitoring within primary health care,’ says Liz. ‘It’s difficult, because there’s no funding for it, but this is our first foray into remote patient monitoring and it’s working well.’ 

‘Our principal doctor, Paresh Dawda, is very invested in how we can use technology to provide accurate, holistic real-time care to our primary health care patients,’ says Diane. 

‘We really have a very unique way of doing things,’ says Liz. ‘It’s very collaborative, with a focus on continuity of care.’  

Ruth agrees that the workplace is unique: ‘Having access to a wealth of knowledge and the peer exchange of knowledge that is so willingly given: I haven't worked anywhere else where that exchange of knowledge and collegial support is enabled like this. And I’ve worked in primary health care for a long time!’ 

The team also benefits from regular staff wellbeing meetings.  

‘That’s another big point of difference from other roles,’ says Diane. ‘It’s a high-pressure role. It’s a lot of work. Management are thinking about our wellbeing, and that makes a big difference.’ 

Barriers to doing more 

Despite the innovations that the practice embraces, current funding models are preventing the team from working to their full potential. 

‘There’s a lack of awareness under the current funding models for the complexity of patients,’ says Liz. ‘The funding doesn’t reflect the complex coordination of care that nurses provide. There is no recognition within the health system of the importance of primary health care nursing. The funding is based around episodic care. It’s changing, but it’s not changing enough to make this work viable in most practices. The grant for our Homebound program is coming to an end. It will be difficult to sustain that program under the current funding models.’ 

‘The importance of primary health care nursing is not recognised at the national, the state or the local level,’ says Ruth. ‘One of the foundations of a good health system is its nurses. We need to push for the funding to recognise that it’s nurses in primary health care that do a lot of the coordination and deliver the care needs. It requires a different type of funding model to the acute care system. But at the same time, primary health care needs to be affordable for patients. 

‘The funding affects everything, including human resourcing. This model of care would have so much more great potential if the funding models were to change so that we could expand our team to include even more specialists.’ 

Liz agrees: ‘We could really use a mental health worker. Chronic pain is another major issue that requires specialist care. And we need to provide more men’s wellness checks.’ 

Looking to the future 

Inadequate funding models are not the only problem plaguing primary health care. Workforce shortages are another serious problem and Next Practice Deakin is doing what it can to attract new talent into the sector. 

Macy has trained with the University of Canberra to supervise students on placements in aged care and she also supervises nursing students on primary health care placements. 

‘We’re welcoming new people coming into primary health care,’ says Ruth. ‘I’ve got two mentees at the moment that I’m supervising. We do a lot of education. We have RNs doing their NP training completing their professional hours component with us.’ 

Setting an example 

Next Practice Deakin provides an exemplary model of what’s already possible in primary health care. And as funding models evolve, even more exciting possibilities in the sector will emerge. The nursing team’s dedication to their patients is strengthened by the collaborative team-based approach that enables targeted individualised care. And it’s clear that these nurses and NPs get a lot of satisfaction and enjoyment from the teamwork.  

‘I'm really proud of all of our nursing staff!’ says Liz. ‘We couldn't do it without each other.’