The need for nursing professionals



Providing continuity and care coordination

  • Nurses can better enable people with long-term health conditions to live well and avoid unnecessary complications or crises, and support people with complex multiple conditions to remain as well and independent as possible, avoiding deterioration or complications in people’s complex health conditions.
  • We know that people living with complex/multiple long-term conditions will do better if a health professional is at the centre of their care, maintaining regular contact with them.
  • Community nurses can make a big contribution toward providing better coordinated care that is centred on clients’ health and wellbeing needs.
  • Nurses can coordinate rapid support to urgent care for people when their health or independence rapidly deteriorates, including effective alternatives to hospital. 

Chronic diseases management in the community

  • Addressing the community burden of complex care needs in the future will involve nursing professionals working with clients at the centre of the care team in the home.
  • Community-based nurse coordinators can work to better integrate home care and primary care services so that care responses are coordinated for clients with complex conditions, and where possible delivered in the home rather than in the surgery, hospital or through emergency services.
  • Community nurse care coordinators can collaborate with General Practice while also drawing from and supporting other organisations and the wider community as they coordinate and maximise the care and support needed for clients.

Frail aged care and people with dementia

  • Even a relatively minor illness can cause a sudden decline in the ability of someone who is frail or who has dementia to function at home – recognising client frailty is a very important step in assisting them remain as well and independent as possible and to avoiding an unnecessary decline in their health.
  • A community nurse coordinator is able to provide assessment and planning and can coordinate an integrated plan for long-term treatment and follow-up where appropriate.
  • The assessment should cover elements such as the clients’ medical, social, environmental and psychological situation, as well as their abilities to function in their daily living.
  • Accurate and early diagnosis of dementia is very important in order to provide information and support for people with dementia and their carers when the condition begins to cause problems that are life-limiting.
  • Service coordination may also be needed to provide assistance to people in navigating and maximising existing care options.

Care for residents through Comprehensive Medical Assessments

  • Residents of care homes should consistently receive the same access to all necessary healthcare services as people living at home.
  • Medicare fund annual health assessments for residents of care homes, which can be conducted by a community-based nurse on behalf of a resident’s GP.
  • These “comprehensive medical assessments” are underutilised and can significantly improve residents’ health and care.
  • Assessment of residents’ health should be a continuous and regular process; not a one-off event when they enter the care home.