Change Management from “ Home visit ” To “ Home nursing care ”

1. Change Management from “Home visit” To “Home nursing care” Presented by Mrs.PhensiriAtthawong, Mrs.WasanaChungtragoon and Mrs.NitthananAnusornprasert From : Community Nursing Department of Songkhla Hospital, Songkhla Province, Thailand

2. Rational • the number of patients on bed are likely to increase every year (data from Continuing of Nursing care Center (COC) of Songkhla Hospital) ; 45, 80, 83 and 103 cases per 100,000 population respectively) • community nurse is therefore necessary in helping on bed patients as well as their caregivers to handle their own selfcare which consequently can reduce complications and increase good life quality. • According to continuous nursing model development in term of home visits, focusing on quality system as per criteria set by Bureau of Nursing council in Thailand.

3. Objective • To developed the model of home visit • Caring patient at home in order to prevent any other illness conditions including complications • to follow up and assess health care result as well as solve problem to achieve a better life quality in all patients, caregivers and families.

4. Strategic of Development Model Model Development Patients’ hospital ward caring is adapted to use for patient caring at home by • using Primary Care Unit (PCU) as a nurse station • a patient’s home as a ward • a community nurse as case manager • a caregiver as a nurse’s aid • community volunteer and other concerned parties as a multidisciplinary team.

5. Input Visiting Team • PCU’s team member • Multidisciplinary Team ( Physician, Physio therapist, Dietician, pharmacist, etc.) • Concerned Party Network (community volunteers, Local authorities ) System Management -Set visiting system focusing on bed patients • -Implement home visit flow charts • -Study patients’ history of illnesses • -Co-ordination with concerned party network and multidisciplinary team Resources • Medical tools Supportive Factors • Relatives and caregivers • Community volunteers • Concerned party network System model Process Home Visit Service • In charge system usage • pre-conference prior to home visit • -Home visit • -Post-conference for knowledge sharing and future planning for continuous nursing care • Nurse note on nursing care history of visited patients in the provided form Nursing Care Co-ordination at home -Provision of COC in order to link caring system from hospital to community and from community to hospital -Support multidisciplinary team through e-mail, line, skype, telephone) Output/Outcome 1.The coverage of visiting patients type 3 at home > 80% (results 100%) 2.Satisfation of customers > 80% (results 97.14%) • .Satisfaction of providers > 80% (results 94.79%) • .The incidence of complication in patients < 5% (result 2.8%) • .Patients can control progression of disease and handle their own > 80% (results 94.79%) • 6.Crisis Patients who need to refer has been refer in time 100% (results 100%) Feed back

6. Conceptual Framework of Home-Nursing Care System Development Teamwork Empowerment Achievement Service mind “SEAMLESS Team” Management Safety Engagement Life style

7. Change Management “Home visit” To “Home nursing care” Thank you