model practice in community health center ljubljana ... · •module - management of asthma and...

MODEL PRACTICE IN COMMUNITY

HEALTH CENTER LJUBLJANA; WORKING

TOGETHER AS ONE, DOES IT WORK?

Metka Žitnik

E-mail: metka-zitnik@zd-lj.si

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Today, more than ever, medicine is

a group activity rather than an individual one.

Due to this change in how we view medicine individual professions now demand

acknowledgement and recognition of skills and competencies.

To be esteemed, respected,

and acknowledged for one's contribution!

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WHY HAVE WE CHANGED THE WORK

METHOD?

• Due to the aging population there are more andmore patients with chronic diseases in Slovenia,

• the transfer of work from secondary to primary levelis increasing,

• the number of chronic patients is rising,

• the education and demands of patients areincreasing,

• the number of patients managed by a single doctoris rising.

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FROM THEORY TO PRACTICE- MODEL

PRACTICE

• A nurse practitioner is in charge of performing

routine/prevention check-ups and managing

chronic patients with chronic diseases.

WHAT DOES THE LITERATURE SAY?

• Research studies of patients with several chronic

diseases show that such patients have a positive

attitude towards the new work method (Fortin et

al, 2010).

• Patients receive more practical advice on how to

maintain or improve their medical condition and

take their medicine (Haidar, 2007).

• With the help of a nurse practitioner the quality of

the treatment increases significantly and

consequently the health and well-being of the

patient improve (Redsell et al., 2007).

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HOW TO IMPLEMENT SUCH WORK

METHOD?

• Vision,

• good plan,

• professionals of all involved disciplines (gp, nurses, ect..),

• quality indicators,

• numbers are important,

• evidence,

• courage!

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IT WASN'T THAT EASY

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ADITIONAL EDUCATION

• Module - management of asthma and COPD in a model practice,

• Module - hypertension and management of a patient with chronic hypertension,

• Module - diabetes,

• Module - prevention,

• Module – osteoporosis,

• Course in mediation

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TRANSFER OF COMPETENCE FROM

DOCTOR TO NURSE

• Management of chronic patients with diabetes,

hypertensia, asthma, copd, depression,

osteoprosis, benign prostatic hyperplasia,

• Independent decision-making (lab test, ekg,..),

• Doing cardiovascular prevention,

• Professional license.

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WHAT DO WE DO?

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PREVENTION

KEEPING

A REGISTER

AND

REPORTING

ABOUT ONE'S

WORK

MANAGEMENT

OF WELL

MANAGED

CHRONICAL

PATIENT

‘’MY’’ POPULATION

• 3775 PATIENTS

• 334 DIABETES

• 1193 HYPERTENSION

• 97 COPD

• 171 ASTHMA

• ... AND SO ON...

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MY WORK DAY

• PREVENTIVE CHECK-UP;

• All patients over 30 years,

• Systematic checking/screening,

• Use of standardized questionnaires.

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MY WORK DAY

• MANAGEMENT OF CHRONIC DISEASE AND

PREVENTION HAN IN HAND

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INTERPROFESSIONAL

COLLABORATION

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NURSE PRACTITIONER

Simulation center

Community nurse

Health care promotion center

GP

Patient

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MY WORK DAY

• KEEPING REGISTERS AND REPORTING

ABOUT ONE’S WORK

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BENEFIT?

• Extended team aproach,

• In-depth and systematic implementation of

prevention,

• Better medical surveillance of the population,

• Registers of chronica diseases,

• Better management of patient with chronic non-

communicable diseases.

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NEWLY DIAGNOSED PATIENTS

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ASTHMA COPD DIABETES HYPERTENSIA DEPRESSION

2012 720 798 2442 3578 278

2013 690 833 2481 5581 754

2014 848 931 3366 6551 1669

2015 982 943 3723 8015 2631

GOOD RELATIONS, GOOD WORK!

• During their work, nurse practitioners establish a

wide range of relations with patients and with

their colleagues.

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• It has been proved that good collegial relations

among nurse practitioners and doctors improve

the outcome of the treatment; however, it is too

often the case that relations between these two

working groups function on the principle of

hierarchy or competitiveness, which harms

patients (Klemenc, 2007).

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OUR TEAM BUILDING

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• An American study from 2010 revealed that a

group of several women has a higher collective

intelligence and makes better, more successful

decisions, regardless of how smart and

experienced the individuals in it are (Williams

Woolley, 2010).

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People keep saying that

something can't be done,

until someone comes along

...and does it!

Florence Nightingale

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THANK YOU