Introduction: The increasing prevalence of multi-morbidities among people living with cardiovascular disease (CVD) has increased the complexity of their clinical care. Implementing the role of advanced practice nurses (APNs) in integrated models of care has been shown to improve outcomes in the CVD population. However, cardiac patients’ perceptions and acceptance of the role of APNs have not been examined in Singapore.

Methods: An exploratory descriptive qualitative design using semi-structured face-to-face individual interviews was undertaken with cardiac outpatients (November 2017 – March 2018). Outpatients with CVD were purposively sampled from a national cardiac centre in Singapore. Data were analysed using thematic analysis. COREQ guidelines were adhered to.

Results: The sample was multi-ethnic (43% Indians; 36% Chinese; 14% Malays; 7% Eurasians), ages ranged from 41 to 80 years. Two main themes were identified: (1) APNs play a complementary role to doctors and (2) the acceptance of the APN role takes time. Each theme was supported by three subthemes to further elucidate the role and acceptance of APNs.

Discussions: From cardiac patients’ perspectives, APNs play a complementary role to doctors and add value to patient care. Despite appreciating the value APNs bring to healthcare, cardiac patients’ acceptance for APNs is not yet optimal due to the lack of understanding of what APNs do. Therefore, there is a need for APNs themselves and for healthcare services to put in more efforts to inform the public of this new model of care.

Conclusions: Limited research has elucidated patients’ perspectives towards the role of APNs in Asia, in comparison to mature contexts like the UK, the USA, Canada and Australia. This study illustrates how despite experiencing the value APNs bring to care, cardiac patients preferred seeking outpatient consultations with doctors as these were what they were accustomed to. A lack of understanding of the role of APNs is present, thereby causing less than optimal patient acceptance of APNs. As cardiac patients gain greater exposure to APN-led services, they may increase in appreciation for and be convinced of APNs’ competence in managing their chronic conditions.

Lessons learned: Patients need to be convinced that APNs are qualified healthcare professionals. The utilisation of APNs in integrated models of care may accentuate the APN role. Greater efforts are needed to publicise the APN role through strong medical and nursing voices.

Limitations: The strength of adopting a qualitative methodology, i.e. the purposiveness of the study participants, was a limitation. The study participants were cardiac patients who were recruited from one national heart centre, thereby limiting generalisability. Nonetheless, the intention of this study was not to generalise but to allow for the transferability of knowledge from one context to another. The study findings can possibly be transferred to similar contexts where cardiac patients require long-term outpatient services.

Suggestions for future research: Strategies to increase patients’ awareness and acceptance of expanded nursing roles in integrated care models that moves away from conventional physician-centre care can be explored.

Introduction
The Integrated Skin Cancer Clinic was established as a partnership between South Eastern Sydney Local Health District (SESLHD) and Integrated Specialist Healthcare Education and Research Foundation (ISHCERF) to address the growing need for high quality, bulk billed skin cancer services.
Prior to the initiative it could take more than three months to see a local Dermatologist and out of pocket costs may have prevented clients from using specialists.

Practice change implemented
A model was built around integrated care principles to up-skill local General Practitioners (GPs) and create networks with Dermatology and Plastic Surgery. For clients this is a ‘one stop shop’ providing access to high quality assessment and treatment with no referral required.
A free six month training program was established for GPs. Once completed, the GP is working to the extent of their scope of practice with direct referral pathways for complex cases.

Aim and theory of change
The aim is to provide a high quality service under one roof with minimal waiting times with no referral required. The use of GPs enables bulk billing, ensuring that there are no barriers to skin cancer assessment and treatment.
Integrated Care theories used in this model are partnerships, pooled funding and multidisciplinary care.

Targeted population and stakeholders
Anyone can access the service easily and in most cases it is bulk billed, making the service truly accessible to all. It is based in the Sutherland Shire (a known hot spot for melanomas).

Timeline
The skin cancer clinic started in June 2015 and became self-sustaining by November 2017.

Highlights
The clinic was a finalist in the NSW Premier’s awards in 2018.

Sustainability
The skin cancer clinic became self-sustaining in November 2017 as client numbers gradually increased. Other clinics using this model will also become sustainable as client numbers grow.

Transferability
This model has proven highly transferrable to other disease states and other locations.
It has already spread to Figtree, Hurstville and Macquarie (NSW). It has been used to improve chronic wounds, obesity, joint health, breast health and there are plans to spread to other clinical areas in the near future.

Conclusions
Community members have found the clinic very accessible as seen by the growing numbers of clients.
GP feedback has shown that the training program enables the GPs to work at the extent of their scope of practice and provide higher quality skin cancer checks to their patients.

Discussions
Cost should not be a barrier to skin cancer checks as when skin cancers are left undiagnosed or untreated there can be significant harm to the individual and cost to the healthcare system.
Each month the clinic diagnoses and treats multiple melanomas, which if left untreated can quickly spread to other areas and become life threatening.

Lessons learned
Partnerships and pooled funding are essential to this project. Many partners have contributed to this clinic, making it so successful.
The underlying value of healthcare for all and principles of integrated care have made this clinic so effective, efficient and valued by the community.