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Sheridan N et al. – Record review and home visiting uncovered clinical and social information buried in the ‘systems records’ or unknown. Inter–professional case conferences resulted in prioritising interventions before assigning to practitioners for follow–up. Home visiting led to advocacy for social services, not possible in earlier general practice or emergency department (ED) consultations. Specialist hospital physician support in accessing hospital services strengthened the relationship with general practice. Case finding was an unexpected outcome of home visiting with individuals from the same household as the index patient assisted to access services. All model elements – nurse home visiting, record review, inter–professional case conference, and assertive follow–up and intervention—were essential to resolving problems seriously impacting health status.

   

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