Increasing prevalence and complexity of multimorbidity across populations is a global phenomenon [1-3]. This constitutes one of the most significant challenges for health care in the 21st century [4]. In general, care for patients with multimorbidity is fragmented and not coordinated, especially between health care settings, such as primary and secondary care [5,6]. Current models of care delivery focus on single-disease-specific management, resulting in attendance at multiple specialist medical clinics, and do not support continuity of care, placing a significant burden on both patients and hospitals [3,7].

In an attempt to improve efficiencies within health care, nurse-led clinics and services have emerged over the past two decades [8,9]. Their effectiveness has been demonstrated on a number of levels, responding to the complexity of care coordination required by patients [10,11]. This includes the use of a person-centered approach [9], positive patient experience and satisfaction [9,12], and counseling and interventions to support chronic medication adherence [8,13].

In Australia, providing continuity in health care for people with chronic and complex disease is problematic, partly due to differences between federal and state government policies as well as structures and funding systems for the primary and secondary health care sectors [14]. This issue poses a challenge for nurse-led services to provide integrated models of care and lead continuity of care strategies between the health sectors at local service levels. Nurse-led models of care can provide a solution, in part, to the barriers associated with developing nonfragmented care in order to provide effective management for people with multimorbidity. It is, therefore, timely that a model of care trialing cross-sector collaboration is implemented. In Australia, the primary and secondary health care sectors will have congruent access to patients’ health care information through national strategies, such as My Health Record [15] and Health Care Homes [16]. These strategies, although in their infancy, if supported at local service and health network levels, can be used to leverage communication and collaboration by nurses to improve continuity of care. However, there remain few studies examining nurse-led models of care to improve continuity of care [17,18]. Despite the success of nurse-led services in a range of other contexts, their effectiveness in supporting continuity of care between the secondary and primary health sectors for people living with multimorbidity is yet to be determined.

Chronic diseases, including cardiovascular disease, diabetes, chronic lung disease, and cancer, are collectively responsible for almost 70% of all deaths worldwide. In the United Kingdom, the United States, and Australia, between 22% and 25% of the population live with multimorbidity, defined as having two or more chronic conditions concurrently; the prevalence of multimorbidity is even higher in the older population [2].

Multimorbidity is associated with poorer health outcomes, increased care fragmentation [1,19], higher health service utilization, and higher health care costs [20,21]. Existing models of care are based on a medical model of health service delivery and are designed to manage a single disease; therefore, they are not suitable for the complexity of health care associated with the presence of multiple chronic conditions [3,22,23]. Additionally, clinical guidelines predominantly focus on a single disease, potentially contributing to conflicting medication and care management for people with multimorbidity [24]. The traditional single-disease focus of current health care models and practices is also unsuitable for people with multimorbidity due to a lack of holistic care management and coordination [3,22,23].

Continuity of care is acknowledged as an essential component of high-quality care [25]. However, it is evident that chronic and complex health care management poses a challenge for health care systems to provide and promote continuity of care for people with multimorbidity [1]. A person-centered approach rather than a single-disease management program will provide more effective, high-quality care [4]. A coordinated comprehensive patient-centered model that focuses on continuity of care across the health system is especially needed for people with multimorbidity [6,26,27].

The relationship between aspects of continuity of care and patient satisfaction, improved health outcomes, a reduction in hospital admissions, and a reduction in health care utilization has been established [17,25,28,29]. In a recent scoping study [6] it was identified that in relation to multimorbidity management, models and elements of care were focused on general integrated care, as previously applied to single-disease management; therefore, they were unsuitable to the specific care required for the complexity associated with multimorbidity. The details of models of care require further study, specifically the role of nursing and nurse-led services to improve continuity of care and care coordination for people with multimorbidity.

Ethical approval was obtained by the Human Research Ethics Committee (HREC) (reference number: HREC/17/RAH/552) at the University of South Australia (application ID: 200958) and the Central Adelaide Local Health Network (CALHN) (reference number: R20171204).

The overall aim of this study is to determine the feasibility of implementing a nurse-led care coordination service from the outpatient setting to provide continuity of care across the secondary and primary health care settings for people with multimorbidity. The specific aims are as follows:

The setting for this study is an outpatient MACS at a large secondary, tertiary referral, hospital.

This action research study is largely qualitative but includes a quantitative descriptive element. There will be an initial stakeholder forum to develop the domains for a model of nurse-led care coordination. When the model is developed, it will be validated through current literature and a follow-up-focused workshop of stakeholders (see Table 3). Stakeholders at the forum and workshop will include health care staff and executives from both the primary and secondary heath care sectors, as well as other relevant academic and clinical participants (see Table 1). The nurse-led model for care coordination will then be implemented and refined through a series of iterative action research cycles. Data will be collected throughout the action research cycles (see Table 3).

Thematic analysis based on the phases of Braun and Clarke [47] will be used as outlined in Table 4. The process of thematic analysis will identify categories of information and develop model domains for developing a model of nurse-led care coordination. It is anticipated that the model will be pragmatic and consider specific continuity of care strategies to be implemented as part of the nurse-led care coordination service. Thematic analysis will also be used to analyze survey and interview data to reveal patients’, nurses’, and health care staff’s experiences of continuity of care, before and after implementation of the nurse-led model of care coordination. Through the process of thematic analysis, an account of what is happening in the situation (ie, nurse-led service within the multidisciplinary MACS clinic) and how it is happening will be identified [47]. Braun and Clarke’s practical approach is useful for comparing multiple data sources (ie, from patients, nurses, and health care staff) [47,48].

Quantitative data from questionnaires and/or medical records related to patients’, nurses’, and health care staff’s experiences of continuity of care and the nurse-led model of care coordination and demographic data, as well as data relating to the nurse-led model of care coordination, continuity of care, and patient progress or outcomes will be analyzed (see Table 3). Analysis will use descriptive statistical methods including means, medians, and interquartile ranges where appropriate. Differences between variables will be analyzed using either two-tailed t tests or the Wilcoxon ranked-sum test where appropriate. A P value of less than .05 will be considered statistically significant. All statistical analyses will be conducted using NVivo 10 (QSR International) and SPSS, version 25 (IBM Corp).

The nurse-led model will be collaboratively developed at a series of stakeholder—secondary and primary health sectors—forums. The forums will also be developed with reference to the Australian Primary Health Care Nurses Association Building Blocks for nurse-led clinics [45]. A follow-up validation workshop and literature search will further refine the model. Implementation of the model through iterative research cycles will continue the validation process as elements change in response to user experiences. Interventions aligned with the model will be based on real-world experience in the nurse-led service, a consensus approach, and systematic findings from the literature.

Recognized and validated instruments will be used to collect data in relation to continuity of care, patient centeredness, workplace culture, and the practice role and level of the nurses (see Table 2). A concurrent approach to data collection and analysis will allow the separate use of quantitative and qualitative methods within a single cycle of data collection and analysis. This will allow both sets of data to be interpreted together, providing a richer and more comprehensive response to research questions [49].

Nurse-led services and clinics have been widely implemented in primary health care settings and, increasingly, in outpatient departments but not with the purpose of improving continuity of care between the two sectors. The evidence for nurse-led services to improve continuity of care for people living with multiple chronic diseases and complex care needs has not been established. This proposed study is significant because it aims to develop a model of care for nurse-led services, based on both research and stakeholder experience. This model, focusing on patient-centered care and the nursing role to coordinate care to achieve continuity across the health care sector, has not been previously trialed for people with multimorbidity.

It is anticipated that the model of care for a nurse-led care coordination service will support the implementation of continuity of care strategies. These strategies may include assessment of risk of hospital readmission; patient readiness for change; well-coordinated, individualized, multidisciplinary health care plans; patient self-management strategies; and coordinated communication between the secondary and primary health care sectors. Ideally, these will result in improved patient and staff experiences and health outcomes. Development of the model followed by a series of action research cycles of testing and refining the model will ensure that the research incorporates both theory and practical experience related to continuity of care across the health sector. This action research approach will, therefore, focus on what works within a real-world clinical setting. It will produce a patient-centered model of care for nurse-led services that provides a template for continuity of care, articulating the nursing role and service for adaptation throughout diverse health care systems within Australia and potentially worldwide.

As this is an action research design, there are no a priori design of the nurse-led model of care coordination or nursing interventions required. However, as both the model and the interventions will be developed in collaboration with real-world clinical practice and the health care literature, it will be important to ensure concordance between both. No control or comparator will be included within the model assessment, but survey participants who attended the outpatient department prior to commencement of the nurse-led service will be examined. The service setting is geographically limited since it is located at only one site; however, it is anticipated that the setting will be adaptable and applicable to geographically diverse locations. Electronic record and patient data systems vary across health sectors and can pose access and consistency issues. These will be addressed through the highly pragmatic nature of the study, which will focus on relationship building [47] and regular and consistent communication across health sectors as part of the nursing interventions.