Case finding: a new approach to chronic disease prevention

Area of Science:

• Community Health
• Nursing Practice
• Chronic Disease Management

Background:

• Community health promotion events identify individuals with chronic disease risk factors.
• Current healthcare pathways often rely heavily on General Practitioners (GPs) as gatekeepers.
• Effective patient follow-up is crucial for managing chronic conditions.

Purpose of the Study:

• To map the patient journey for individuals identified with chronic disease risk factors at a community event.
• To identify barriers and facilitators in accessing nursing and other health services.
• To evaluate the existing follow-up mechanisms for identified at-risk individuals.

Main Methods:

• A working group comprising Specialist Nurses, Mental Health Nurses, DN Nurse Practitioners, and Community Development staff was formed.
• A patient journey mapping exercise was conducted for individuals identified with chronic disease risk factors.
• Qualitative analysis of the mapping exercise to identify service access points and follow-up gaps.

Main Results:

• The General Practitioner (GP) was identified as the primary and often sole gatekeeper to essential nursing and other health services.
• Patient health outcomes were contingent on the individual's ability to secure a GP appointment.
• No established follow-up or outcome tracking mechanisms were in place for individuals identified at community events.

Conclusions:

• The current system presents significant barriers to accessing care for individuals identified with chronic disease risk factors.
• Rethinking the gatekeeper role of GPs and implementing robust follow-up protocols are essential for improving chronic disease management.
• Integration of community-based identification with accessible service pathways is needed.