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
System model
Home Visit Service
-In charge system usage
-pre-conference prior to home visit
-Home visit
> 80% (results 100%)
2.Satisfation of customers
(results 97.14%)
> 80%
3.Satisfaction of providers
> 80% (results 94.79%)
Nurse note on nursing care history of visited
patients in the provided form
4.The incidence of complication in patients
< 5% (result 2.8%)
Nursing Care Co-ordination at home
-Provision of COC in order to link caring
system from hospital to community and from
community to hospital
Supportive Factors
-Relatives and caregivers
-Support multidisciplinary team through e-mail,
line, skype, telephone)
-Concerned party network
home
-Post-conference for knowledge sharing
and future planning for continuous nursing care
Resources
-Medical tools
-Community volunteers
1.The coverage of visiting patients type 3 at
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
Empowerm
ent
“SEAMLESS Team”
Achievem
ent
Managem
Safety
ent
Engagem
ent
Life style
Change Management