Patient engagement

Patient pathways and flow through a nurse clinic 

On this page:

  • See the elements of patient pathways

  • Plan and coordinate effective patient care

  • • Design a service delivery model that meets the needs of the patient

Patient pathways

Patient pathways describe the process by which a patient moves through your nurse clinic. This includes the: initial contact and eligibility assessment, initial assessment, care planning and coordination, information provision, clinical handover and referral. The Victorian service coordination practice manual 2012 defines the common practices, processes, protocols and systems that support service coordination across Victoria. It is a reference guide for managers who lead service coordination, and for practitioners who implement service coordination. 

Patient eligibility

Defining patient criteria for your nurse clinic is important. You may have already documented this in your project plan, or thought about it when you identified your community health needs. Patient criteria may also include exclusion criteria – characteristics that make the patient ineligible for your service.


How will you get referrals to the clinic? Some typical avenues are:

  • internally from the GP

  • from local service providers 

  • from community groups and schools

  • self-referral

Engage with your networks early to ensure that there is awareness of your new clinic in the broader health community.


Assessment is a decision-making methodology; it is not an end in itself, but part of an ongoing process of delivering services. It is an investigative process using professional and interpersonal skills and in‑depth inquiry to identify relevant issues that will guide a responsive intervention. Use assessment tools that meet consumer, service, reporting and program requirements. Consistent clinic-wide tools and processes provide consistent, higher-quality care. The Victorian service coordination practice manual 2012 describes assessments in more detail. What assessment tools and processes will you use?

"We use the HEADSS (adolescent psychosocial assessment) as the basis for the initial patient assessment" 

Care planning & coordination

Care planning is a common activity in a nurse clinic, particularly in general practice. A care plan is a process for setting and achieving positive patient outcomes that align with the patient's own goals. A typical care plan involves assessing a patient’s care needs, identifying desired health outcomes, planning the treatment and actions to reach these outcomes, and scheduling regular reviews. The plan may also include collaboration between two or more providers in its preparation, the delivery of the agreed care, and review of the clinical outcomes.

In General Practice, the MBS related care planning item numbers, contribute to the funding of nurse clinic models which provide care for patients with chronic and / or complex care needs

Review the MBS items available for care planning. 

Information provision

  • Health literacy

    • Thought needs to be given to the health literacy of the community accessing your clinic. Helping patients understand their own health can lead to increased patient empowerment and better health outcomes. Interventions that assist health literacy include:

      • simple and engaging written materials

      • use of interactive multimedia

      • enhanced interpersonal communication at the patient-provider level, and

      • raising awareness among health care staff.

  • Confidentiality and consent
    • Issues related to confidentiality and consent may arise during the implementation of your nurse clinic. The Good Practice Guide 2012 states “Privacy legislation requires the protection of an individual’s personal information and their right to decide how the information is used, disclosed to or shared with others.
  • Some issues that might arise include:
    • Legal age of consent
    • Capacity to consent
    • Confidentiality of information and how to store information to ensure privacy

 Ensure your clinic's policies align with the Quality and Safety framework used in your organisation   

Clinical handover and referrals

You may refer internally within the clinic or externally to other service provider. Accountability and continuity of patient care is essential for all health providers, including nurses. The development of a clinical handover policy for the nurse clinic is recommended as an integral part of the clinic's governance system, and – importantly – to ensure an accurate, consistent and timely handover of patient information between nurses and GPs and other health professionals.

Your handover policy might also cover the handover of care of patients to another person in the event of an absent clinical team member. Many practices have a 'buddy' system whereby a ‘buddy' follows up results and correspondence or continues the care of patients on behalf of an absent colleague.

Service Delivery 

The Service delivery model needs to be designed to meet the needs of the consumer and the level of skill of the person providing the service. 

Models incude:  

  • Early intervention/ prevention/ chronic disease management
  • Health coaching / motivational interviewing 
  • Care planning and care coordination 
  • Patient Education

Some key principles for inclusion in a service delivery model include:

  • Patient-centred care 
    • Patient-centred care is an approach that recognises the benefits of partnering with health care providers, patients and families, and is associated with better adherence to treatment regimens, greater patient satisfaction and greater patient enablement. 
  • Patient Empowerment
    • Empowering patients provides the opportunity to develop their knowledge, skills and confidence to become an active partner in their health care. 
  • Self-management support and behaviour change
    • Encourages patients with chronic conditions to make decisions and take actions that assist in managing their illness. Techniques such as health coaching and motivational interviewing can be used by nurses to support patient self-management.

• Advocating for patient’s rights

Promoting your clinic

In addition to forming relationships with hospitals, local GPs, and allied health practitioners, it’s worthwhile spending some time considering other marketing avenues to build awareness of your clinic and its services.

There’s no single way to effectively promote your clinic, and different approaches will work depending on your location, clinical focus, and competition. Some tactics that don’t cost much and are simple to implement include:

  • sending information and brochures to local services

  • presenting at local community groups and health services

  • displaying information about the clinic in waiting rooms

Read the nurse clinic case studies for more information


The Australian Primary Health Care Nurses Association acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

© Copyright 2023 Australian Primary Health Care Nurses Association (APNA). All rights reserved. MRM by Bond Software.


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