- Work of nurses in the home care services
- Family treatment of obesity
- Sreening with MUST (Malnutrition Universal Screening Tool)
- Patients’ risk factor treatment with simulations
- Audit of quality methods
- Specializations education of family physician from the field of patients’ treatment in Medical Model Practice (MMP)
Work of nurses in the home care services
Our purpose is to make uniform patients’ treatment on home (on the ground) with community care nurses working in MMP and in this way make possible quality equal treatment to all of them, who cannot come to the clinic.
In this intention was made a Clinical path for cooperation between community care nurses and registered nurses in MMP, which shows us practical screening algorithm execution and treatment of chronic patients on their home and also cooperating processes between registered nurses in MMP.
Ground basis for preparing materials and education execution were protocols for registered nurses in MMP, who were by more than 20 specialists, as from closer professional healthcare spheres as from medicine, accommodated on the field.
50 community care nurses were included in those educated modules:
- Screening chronic noninfectious diseases on the field,
- patient’s home treatment with COPB/asthma,
- patient’s home treatment with diabetes-Type II,
- patient’s home treatment with AH,
- family obesity treatment
- family influence on health and assurance of safe environment for elderly.
Evaluation analyses showed, that registered nurses estimated most of those workshop as high quality, as quality executed advanced study with advices and practical examples, also as how to use knowledge from theory into the practice, by healthcare patients’ treatment.
In workshops was positive ranged the fact, that by the realization was included team accession of specialists from healthcare and medicine.
After training registered nurses followed work on the field. All of registered nurses visited from October 2015 till May 2016 more than 2000 patients on their home. Preventive screening and chronic treatment patients were also executed, based on further questionnaires also with new acquired knowledge of CPC+. Their visits were planned by their selves, or they were directed from family infirmary. Partial results showed, that 50 % treated patients were home endangered with risk factors, 45 % of them had chronic disease and 5 % were completely in good health.
Community care nurses evaluated various factors that affect the patient's health status at home and found out, that 11 % of patients are dissatisfied and 2 % very dissatisfied with the functioning of the family, that 15 % of patients are isolated and all 8 % is very isolated, but at the 21 % of patients is given risk for fall, at 5 % there is given a high risk.
All given data are very important by patients’ healthcare treatment, especially on planning of preventive measures.
Risked patients and their treatment with simulations
Community care nurses have also estimated preparedness on lifestyle changes and in necessity directed patients into Simulation centre (SIM centre). SIM centre wanted to reach individual’s insight by simulations in medicine as empirical method and with its help patient can realize consequences (hard smokers breathing, movement problems after apoplexy of the brain, eyesight problems, accelerated aging process caused of smoking…). With those factors must individual clash in his further life because of unhealthy lifestyle. In this side is the main motivator especially negative experience, which should contribute to individual’s lifestyle changes.
Reached results were very encouraged: reached insight by 85 % patients (N=34) and change of lifestyle in 65 % (N=34).
Community care nurses in some of MMP have also estimated alimentary patients’ status with help of MUST instrument.
All endangered patients were directed to personal physician or in Health-education centre or in program of Family obesity proceeding, where qualified team of professionals guide patients on sincerely and empathic way and also motivate them they have persisted in program.
Family treatment of obesity
Workshop successfulness verify results, as body mass index (BMI) of patients got in average 8 visits lower, from 34, 2 to 31, 4. Greater progress could be seen by younger of 50 years; by them is BMI getting lower: from 35, 7 to 31, 5 and older than 50 years from 33, 4 to 31, 3. Program participants have in this way successfully reduced their weight and improved unhealthy lifestyle.
Quality procedure audit
Through the whole project has been taken quality audit from Norwegian international organization DNV. Quality indicators have been established and presently evaluation educationally abstract by participants.
Recommendations:
- Alimentary treatment on primary care should be part of preventive as clinical treatment.
- Family treatment of obesity should be involved in primary healthcare.
- Screening for undernourished risks with MUST questionnaire should be implemented to all MMP.
- Community care nurses should on the field treat people in complex of preventive also in context MMP of chronic treatment.
- Simulation methods should become a part of Health-education centre headlines.
- Specialization of registered nurses should be supplement by example of work in MMP, with emphasis on team work.
- Strengthening the role of home visits.
- Team working, connecting various specializations in primary healthcare and care for same patient, is necessity.
In spite of, that project is officially conclude, there is his permanence in continuing of MUST execution in community care in MMP, also in usage of knowledge acquired through the help of education, simulations execution in preventive, interest of Section for community care, so in this way screening of alimentary status could be working method of community care nurses in Slovenia.
Heartfelt thanks to all co-workers on this project, who have helped with their work assistance to successful conclusion of it and have consecutive helped on best recognition of CHC Ljubljana, as home as abroad, but the most important it is make more quality patients proceeding.