Eighty-five-year-old Limpopo suffers from various chronic diseases, such as diabetes, chronic bronchitis, peptic ulcer, degenerative arthritis and so on. He regularly visits rheumatology immunology, cardiology, metabolism and endocrinology. Every time he goes back to the hospital, it takes him half a day to see a department, until the comprehensive nursing clinic of Hualien Tzu Chi Hospital intervenes. As long as he sees a cardiologist, the doctor can integrate drugs, saving the time of going back and forth to the hospital.
One-stop interdisciplinary nursing shortens the time of seeing a doctor.
Hualien Charity Hospital cooperated with the "Patient-centered Integrated Care Plan for Hospital Outpatients" of the Central Ministry of Health Insurance to set up an integrated care clinic, consisting of 12 medical teams, to provide interdisciplinary one-stop medical care, avoid patients going back and forth to the hospital, avoid repeated medication and examination, and ensure medical safety.
Luo Qinghui, vice president of the Department of Geriatrics and Community Medicine, said that the comprehensive nursing clinic was first evaluated by the doctor, and then comprehensively evaluated by the case manager, and the daily life function was measured. After that, the case manager made a special nursing plan, anti-fall exercise and health education for the parts that needed to be strengthened, and then referred the patients to nutritionist Yamatonokusushi according to the patients' needs, so as to provide appropriate medical care for the patients in a team way.
Follow-up patients with more visits to help integrate outpatient visits.
Song Meihui, the case manager, pointed out that if there were more than three chronic diseases in the past three months and more than two doctors saw a multi-disciplinary patient; Or patients who have prescribed more than two prescriptions for chronic diseases continuously and used more than ten drugs cumulatively are the clients of comprehensive health care clinics; In addition, the service of tracking high-frequency patients has been added, such as seeing patients more than 90 times a year. Nurses will intervene and ask patients' wishes to help integrate outpatient services.
The case manager in Song Meihui reminded that patients who are assessed as suitable for comprehensive nursing clinics by doctors can directly choose the time of comprehensive nursing clinics when they see a doctor, and they can enjoy multidisciplinary services at one visit, and the medical quality has also been greatly improved.
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