HCV Nurse Role:
What does the future look like?
Margaret Fraser: Hepatology Clinical
Nurse Specialist, Dunedin Hospital
A New Dawn is Arising
New Models of Care Needed for the
Future
• By 2020 there is predicted a shortfall of
20,000 nurses in New Zealand, 800,000 in
Australia and shortfalls in the UK and USA.
• NZNO developed a vision for nursing
‘Innovative and flexible models of care - person
centred. Technology, enhanced communication
and new treatment modalities will be utilized to
ensure its appropriate, cost effective and meets
the needs of all people.
Models of Care and how they
contribute to health outcomes
Jill Clendon: New Models of care needed for the
future: Kai Tiaki Aug 2013
Chronic Liver Disease
Hepatitis A, B and C
NAFLD
Alcoholic Liver Disease
Cholestatic autoimmune liver disease: PBC,
PSC
• Haemochromatosis
• Post liver trasplant
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Impact of NAFLD
• NAFLD/NASH emerging as a
major liver related health
issue → metabolic
syndrome
• 40% of New Zealanders
considered obese
• Expected to surpass HCV as
major cause of End Stage
Liver Disease and
transplantation
Alcohol
• Significant increase in
alcohol related
admissions as a result
of hazardous drinking
result in increased
alcoholic liver disease
• Increasing alcohol
abuse in women
Liver transplantation
• HCC increasing. Regular
surveillance results in early
recognition with successful
outcomes
• Increasing numbers of
people transplanted
requiring on-going
monitoring
• Monitoring for: immune
suppression, infections,
rejections, renal failure or
malignancy
HCC Monitoring
• Multidisciplinary care improves / results in
improved quality of life for patients.
• Decreased disease progression
• Earlier stage diagnosis
• Improved survival
End Stage Liver Disease
• Management of ESLD
previously a purely
supportive care model
• Now actively managed with
- volume paracentesis
- TIPS,
- treatment of hepatorenal failure, endoscopic intervention for
oesophageal varices
- liver transplantation.
US Data
• Burden of cirrhosis expected to increase
• 30,000 new cirrhosis diagnosis per year
• Cirrhosis complications result in 150,000
admissions / year
• The majority of patients diagnosed with
cirrhosis should be viewed as a chronic
condition similar to diabetes and
cardiovascular disease
• Medical management of cirrhosis benefits from a
large body of high quality of evidence and
practice guidelines outline standards of care
• Despite the evidence many patients fail to receive
proven treatment
• > 30% of the patients were readmitted within 1
month of discharge
• Expanding body of knowledge makes it difficult to
for GP’s to follow the literature in all subjects
• Gastroenterology consultation was associated
with improved outcomes for patients hospitalised
with decompensated cirrhosis
• Gastroenterology one of the most highly
requested but difficult-to-access referral due to
low numbers of gastroenterologists
Chronic Care Model
Gastroenterologist
Chronic Care
Model
Multidisciplinary
clinic
Manage care
between visits
Improved
access
Patient
Communications
Interventions
Improved Access
Patients Home
Primary Care Physician
Chronic Care Model
Manage care between
visits
Cost impacts of liver disease
• Australia: health costs of treating liver disease in
2012 = $386M
• Productivity impacts of liver disease: est $4.2B
• Informal care: ie families / friends caring cost
$259M
• Cost of liver disease is 40% more costly than type
2 diabetes and chronic kidney disease
Cost saving / benefit in as per Deloitte
Access Economics GESA paper
• Total financial cost associated with liver
disease estimated at $5.4B in 2012
• Estimated burden of people = 529,376
• A GESA-led initiative costing $6M / year a
break even point is reached with a reduction
in 585 people each year = 0.11% of the target
population
Education / Intervention
• Preventative measures: vaccination HBV,
increase awareness of risks of excess alcohol,
controlling factors for those at risk of NAFLD
• Screening: HBV + HCV, Haemochromatosis,
HCC and those with metabolic disease
NAFLD
Nurse-led community based care
model linked to a hospital liver centre
• Preventing the progression of liver diseases,
screening for complications of liver disease and
admission avoidance by early detection of
complications related to liver disease
• Assist with screening programmes for HCC
• Linking patients with alcohol related liver disease
to CADs services
• Referring patients for nutritional support, lifestyle
modification etc.
Be Prepared / Education
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Post Grad papers
Self Education on liver disease
Keep up to date with the latest data
Join the Australian Hepatology Association
www.
Restructuring – NZNO to Review Job
Descriptions
• Impact on senior nurse roles
• Positions may be amalgamated, removed,
enhanced or downsized
• Evaluation does not include: individual
performance, years on the job, commitment to
employment, work or case loads, relieving for
other roles, on-call requirements, additional
duties over and above job description
requirements
• Details found in JERC Appendix 1 (c) of the MECA
Factors in Evaluating New Job
Descriptions
• Influence and impact on the outputs of the DHB
• Complexity of problem-solving / clinical decision
making
• Latitude or scope for action
• Breadth of activities
• Supervision of staff
• Interpersonal skills
• Knowledge requirements
• Experience requirements
References
• Deloitte Access Economics: GESA, ALA ‘The economic
cost and health burden of liver disease in Australia.
January 2013
• Clinical Gastroenterology and Hepatology: Jessica
Mellinger and M Volk ‘Multidisciplinary Management
of Patients With Cirrhosis: A need for Care
Coordination 2013;11:217-223
• Jill Clendon: New Models of care needed for the future:
Kai Tiaki nursing New Zealand. Vol 19 no 7 Aug 2013
• Statement by the New Zealand Nurses Organisation
and the College of Nurses Aotearoa: Articulating the
difference between PDRP level 4 RN roles and those
advanced practice roles requiring not only nursing
expertise but also positional authority