Nurse-led clinic models

There are five nurse-led clinic models that you may choose to implement in your practice, you can read more about these below.

Regardless of the model you implement, you can choose to address any chronic disease including:

  • cancer
  • cardiovascular disease
  • chronic kidney disease
  • chronic respiratory condition (including asthma)
  • diabetes
  • musculoskeletal conditions (athritis and osteoporosis).

If you require further information about these models or have any questions, please contact your Health Coordination Consultant. If you think you would benefit from speaking with the practice who developed this model please liaise with your Health Coordination Consultant, who can seek to contact the practice on your behalf.

This model provided group education sessions led by nurses and involving, GPs and allied health staff. The aim was to educate and empower patients over 70 years of age, about how to recognise and/or avoid the health complications of osteoporosis.

Patients played a key role as active participants in an initial focus group. They had the opportunity to provide feedback which helped shape the program structure, ensuring it was more consumer focused and met patient needs.

The program was structured into three sessions:

  1. session one focused on osteoporosis education
  2. in session two patients set goals for their bone health
  3. in session three, two allied health providers (a dietitian and exercise physiologist) provided practical information on small lifestyle changes participants could make to improve their bone health.

Further information can be found at the following links:

This model provided nurse-led diabetes consultations. Working together the nurse and GP developed a structured template for diabetes review, then ran a series of consultations with a target group of patients with high-risk diabetes mellitus type 2.

Since completing the funded program, the practice has continued to offer nurse-led diabetes consultations as part of its standard diabetes care for high risk patients.

Further information can be found at the following links:

This model was implemented to manage the increase in patients presenting with exacerbation of COPD and asthma during the winter months.

Before the clinic started, the practice reviewed their current systems, upskilled their practice nurse in spirometry and established new workflows. High-risk patients were then identified and contacted by reception staff to attend the clinic.

During the six month trial implementation, the practice nurse undertook patient assessments which included spirometry testing, medication technique and compliance, as well as self-management education. High-risk patients were seen by the GP or referred to a specialist.

Patients were then followed up at six months to assess their progress and the effectiveness of their management plan.

Further information can be found at the following links:

This practice was able to pilot two respiratory clinics; one focused on asthma and the other on Chronic Obstructive Pulmonary Disease (COPD). At each clinic, a series of patients were seen individually by their care team which consisted of their GP and primary health care nurse, working alongside the visiting respiratory educator.

To support the upskilling of practice staff, the respiratory educator ran pre and post-clinic education sessions.

The practice has since run two additional clinics, without requiring the attendance of respiratory educators, and intends to offer respiratory clinics for its patients in the future.

Further information can be found at the following links:

In this model, patients were offered the opportunity to participate in a 12-week weight management program.

A review of practice records identified that 50-70% of patients were overweight or obese, with several hundred of these patients also diagnosed with other chronic conditions including hypertension and diabetes.

The 12-week program involved each patient having an initial GP consultation to set up a care plan. This was followed by weekly visits with the practice nurse to monitor progress and monthly visits with the GP for review. Referrals were made to relevant allied health professionals.

This project has proven sustainable, with the practice considering applying the model to other chronic illnesses.

Further information can be found at the following links: