Meeting the needs of vulnerable patients: The need for team working across general practice and community nursing services

Abstract

. The role of the district nurse is developing to reflect the needs of health care outside the hospital including advanced practice -for example, independent prescribing. . District nurses working in localities with clusters of general practices can contribute to personalised proactive care and the support of individuals in their own home, which is essential to strategies to reduce avoidable hospital admissions and improve care for vulnerable patients. . High-quality care for patients being case managed can be facilitated by teamworking between general practice and community-based nursing services, supported by regular team meetings, named clinicians and shared projects. Why this matters to usDistrict nursing services play a key role in supporting vulnerable individuals with complex healthcare needs to remain in their own home and die at home if that is the choice of the individual and their family. The district nurse has the skills and expertise that can play a key role in co-ordinating care for people with long-term conditions and the avoidance of unnecessary hospital admissions. As such, district nurses are key members of the primary healthcare team -however, in some areas, service reconfigurations have reduced teamworking between general practitioners and district nurses, and reduced understanding of each other's role and expertise. We believe that working closely with general practice provides an opportunity to further develop and enhance the district nursing service and deliver effective health care to the local population. New ways of working, including communityorientated integrated care, can further develop teamworking to support the delivery of high-quality care to increasingly vulnerable patients. ABSTRACTGeneral practitioners and district nurses have a long history of providing care outside the hospital setting. With health care increasingly moving out of the hospital setting, there are more opportunities for general practitioners and district nurses to work together to meet the health needs of the local population. However, the reduction in qualified specialist practitioner district nurses over the last decade is concerning. The need for an effective district nursing service has been recognised by the Department of Health in their own model -the nature of district nursing work, often over a long period, enables relationships to develop with the patient, family and informal carers as a basis for anticipatory care to manage long-term conditions. Communication and understanding of the role are central to enhance effective working between general practitioners and district nurses, which can be fostered by engagement in community-oriented integrated care and case management.

Understanding Dysphagia Care in the Community Setting

“…Health policy changes in many settings encourage early discharge from acute care services, with some facilities now offering 'hospital-at-home' care in lieu of an acute admission [1]. At the other end of the care continuum there is also increasing support for people to remain at home and out of nursing home/residential care for as long as possible [2,3]. Other influential factors include the aging population, people living with more chronic and complex conditions [4], and a shift to person-directed care and self-empowerment in healthcare [5][6][7].…”

Intersectoral communication amongst healthcare providers regarding care plans: a scoping review

“…The importance of relationships across sectors Sources reviewed featured a variety of intersectoral communication relationships and pathways. Twelve sources examined communication from health to community sectors 25 , 31 – 33 , 36 , 37 , 39 , 41 , 43 , 49 , 51 , 52 and four investigated the opposite direction of communication; community programs communicating to the health sector. 26 , 27 , 46 , 48 Five sources included communication between health and social sectors, 26 , 28 , 30 , 38 , 47 and another four explored interactions between health sectors (primary, secondary, tertiary), 38 , 40 , 47 , 50 other pathways included primary care to pharmacy 45 , 47 and informal care providers.…”

“…The importance of community navigators in sharing the care plan and goals of care To facilitate communication between health sectors, the importance of an individual that acted as a liaison between sectors, often acting as a broker between various practices, was noted by several sources. 33 , 43 , 49 – 51 , 53 , 54 This figure took on numerous titles; namely, community matron, 33 nurse navigator, 54 a broker, 50 nurse facilitator, 43 or liaison nurse. 49 In considering the aforementioned articles depicted the importance of this role and its usefulness from both the perspective of patients and the care team.…”

Presence: the cornerstone of spiritual needs among hospitalised patients

“…According to this study, another aspect of the presence phenomenon concerns receiving support, which includes three subthemes, namely, receiving empathy, attention and affection, and services from others. People become vulnerable and need more support, due to being both ill and hospitalised . Empathy is a basic concept in the presence phenomenon and an important foundation of patient‐based care .…”