Change Management
from “Home visit” To “Home nursing care”
Presented by
Mrs.Phensiri Atthawong, Mrs.Wasana Chungtragoon
and Mrs.Nitthanan Anusornprasert
From : Community Nursing Department of Songkhla Hospital,
Songkhla Province, Thailand
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.
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.
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.
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
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)
1.The coverage of visiting patients type
3 at home
> 80% (results 100%)
2.Satisfation of customers
(results 97.14%)
> 80%
3.Satisfaction of providers
> 80% (results 94.79%)
4.The incidence of complication in
patients < 5% (result 2.8%)
5.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%)
Conceptual Framework of Home-Nursing Care
System
Developme
nt
Teamwor
k
Service
mind
Empower
ment
“SEAMLESS Team”
Achievem
ent
Managem
Safety
ent
Engagem
ent
Life style
Change Management