Description
Chronic disease management is a challenge for the future of health systems everywhere not only in Slovenia. The Comprehensive Partner Care (CPC)+ project partners intend to tackle this problem at the primary care level. We plan to upgrade an innovative and already established model of comprehensive patient care with new clinical paths and strict quality based process evaluation based on Donor partner’s contribution. The project focuses on early disease detection and improved patient care, especially for patients at risk of chronic non-communicable diseases, elderly, chronically ill patients, and those with poor access to healthcare. This will be achieved with an up-to-date approach: cooperation between the model general practice team (general practitioner, licenced and registered nurse) and a home care nurse according to predefined screening rules and clinical paths supported by systematic assessment of quality and safety for patients and medical staff. Professional personnel (50 family medical residents, 50 home care nurses and 35 teams) will be trained in the framework of 18 modules, according to the new model, which will be also realized in practice. The donor partner, DNV, is involved in all project phases.
Summary of project results
Slovenia is faced with the growing problem of chronic non-communicable diseases. The healthcare system is built on principles of the WHO and is based on the system of community-oriented healthcare centres with focus in teamwork and community. The project aimed to modernize and strengthen family practices where cooperation takes place only between the physician and middle nurse with new quality aspect based approaches, educated personnel in extended teams and empowered patients. The project was focused on the modernization of family model practices with the following objectives: developing two new clinical paths, educate members of family practice, include home nurse to family practice team, involve patients with poor access to healthcare services, introduce family approach to obesity treatment, introduce simulation centre for persons at risk and implement improved quality indicators and standards to primary healthcare. Project’s outcome is the comprehensive CPC+ approach with 2 new clinical pathways, realised in practice and defined in the resulting standard, 214 educated professionals and a list of agreed recommendations. Project’s outputs are two new clinical paths with 19 training materials for all involved professionals and patients that were taught in 46 courses. Both clinical paths were piloted and verified in target population groups of more than 2000 patients and combined with a new family oriented weight loss program and simulation program for patients at risk of lifestyle caused chronic non-communicable diseases. All project outputs were evaluated for quality aspects which resulted in a new CPC+ standard. Main beneficiaries are persons at risk that were visited directly by home care nurses and involved in related programs. Beneficiary is also the national healthcare system itself that was informed and involved in project activities and could benefit from project results. In project acquired knowledge and practices will stay in use in the biggest healthcare centre in Slovenia in the future. Furthermore, project recommendations were already presented to major Slovenian healthcare stakeholders and will be used as the basis for the nationwide implementation. Donor partner’s role ran throughout the whole project recommending quality related approaches, evaluating quality aspects and preparing the framework of the new CPC+ (Upgraded Comprehensive Patient Care) quality standard for primary healthcare, thus achieving high intensity of cooperation and excellent outputs.
Summary of bilateral results
The bilateral achievements can be seen in quality assurance where with successful combination of the educational part with the possibility of piloting the acquired knowledge through simultaneous development of quality parameters and approaches (donor partner). The essential achievement of the project is the joint development of the CPC+ (Upgraded Comprehensive Patient Care) standard for family medicine practices. Even before that the quality criteria for specialist training in family medicine, nurses and teams in family practises were defined. The list of quality indicators for work in so-called model practices with an extended medical team (doctor, registered nurse, nurse and home care nurse) was set and confirmed. Even though the partners cooperated prior the project implementation (Project promoter and the donor partner), the project has brought a very welcomed opportunity to deepen the cooperation in the field of development of a standard that without the bilateral fund would not be possible. The groundwork for the construction of a new approach on how to treat patients in primary health care was set up, representing an original approach in Europe and not only at the national level. All three aspects of implementation: education, realization/piloting and quality control, we have successfully combined in a way that will be continuously used in patient care in Slovenia, and possible will be taken over beyond the borders. For the CPC+ standard, which was created in collaboration with the donor partner, one of the world's leading houses for standardization in healthcare (DNV GL), the bilateral cooperation allowed that it derives from in practice certified (piloting) measurements, which confirmed the suitability of a team approach, the integration of a home care nurse, empowered patients and a selection of educational contents, suitable for all types of professionals involved. A great visibility comes with that what the project has reached on an international professional’s field at the WONCA Europe Congress (World Organisation of Family Doctors) and at the European meeting of nurses in London.