| Objective:Based on the current situation that the health problems caused by stroke in the location of action are becoming more and more prominent,and the hospital-community-family continuous care program is not perfect.According to action research method,through finding problems,analyzing problems,plan,implementation plan and scheme evaluation this five stages,the purpose of this study was to construct a practice model of stroke case management and continuously modify on multi angle and optimize it in clinical application,discuss the effect of the implementation of this model,and provide reference and basis for standard stroke nursing practice.Methods:Based on the framework of action research,this study optimized and revised the practice model of stroke case management in a two-round action cycle according to the spiral process of "diagnosis,planning,implementation,evaluation and reflection" of action research.The first stage,the problem discovery stage: In clinical practice of stroke care,researchers found that there were problems such as incomplete coverage,non-standard content,and lack of continuity of nursing plan in China's stroke care,while the practice mode of case management was the applicable method to solve such problems.The second stage,analysis of the problem stage(diagnosis): To understand a series of problems in the care of stroke patients through literature research and investigation and research,and to understand the disease care needs of patients and caregivers.The third stage,the planning stage(plan):Researchers preliminarily builds a stroke case management practice model through theoretical research,literature research,brainstorming by action research groups,and expert discussions.The fourth stage,the implementation plan stage(implementation): Researchers chooses the stroke center and neurology department to implement the stroke case management practice mode,adopts participatory observation method and focus group interview method to collect problems,opinions and suggestions in operation,and combine Researchers and the action team's reflection and discussion jointly optimize and revise the plan.The fifth stage,program evaluation stage(evaluation): Using convenient sampling methods,68 stroke patients and their caregivers who implemented the revised practice model of stroke case management from November to December 2018 were randomly selected,compared with those from November to December 2017.The 68 stroke patients and their caregivers who implemented this case management model were compared before and after,through the patient level(activity of daily living,neurological impairment,poor prognosis,incidence of related complications,health education awareness rate,discharge satisfaction,etc.),caregiver level(caregiver care ability,quality of life),doctors and nurses level(the satisfaction of doctors,nurses and community nurses,awareness and acceptance of case management models),and medical and health resource utilization level(Times of return visits,outpatient visits,emergency visits,re-hospitalization,average hospital stay).Using descriptive statistics,normality test,f test,t test,rank and inspection,analysis of variance,chi-square,repeated measurement methods to comparative the difference of 1,3 and 6months of data before and after the intervention,and evaluate the impact and effect of the case management practice model on patients,caregivers,medical care and medical systems,and provide suggestions and opinions for the development of the second cycle of action.The second action cycle is based on the research results of the first action cycle to diagnose,plan,implement,evaluate and reflect on the second round.Results:1.Results of the first round of action research: Clinical status studies have found that stroke patients and their caregivers have higher care needs,including the need for disease care knowledge and skills,continuous care management and social support.Hospital continuous care management for stroke patients is currently limited to out-of-hospital follow-up,with many and complex blocking factors.Community health service centers lack the cognition of continuous care management for stroke patients,and the linkage and guidance of the hospital community is an important solution.Literature study found that patients with cerebral apoplexy in poor health management,early rehabilitation training lack of normative,family caregivers pressure,courtyard outside the continuity of care care disconnect phenomenon,dominated by nursing of multidisciplinary collaboration safeguard mechanism is not sound,the key elements in case management model and link quality control needs to be promoted.Through theoretical research,literature research,and action group discussion,based on the guidance and care model,a preliminary stroke case management practice model is constructed,and the plan is continuously optimized through the preliminary implementation and evaluation stage,and finally formed by a full-time case manager led and part-time case manager assisted.It includes a multi-role disciplinary team of physicians,rehabilitation specialists,dietitians,psychologists,pharmacists,etc.,to implement assessment,monitoring,support,education,self-management,communication and coordination from hospital admission to discharge,to the community,family and other whole-course disease care management process.After the implementation of stroke case management,the patient's disease care outcome was significantly improved at the patient level.The patient's disease rehabilitation indicators,such as blood pressure,blood lipids,and blood sugar control,were significantly better than the control group(p<0.05),activities of daily living,and neurological deficits The degree,poor prognosis,and related complications were also significantly better than the control group(p<0.05).At the level of caregivers,the caregiver ability and the quality of life were significantly improved.The each dimension scores and total scores of all dimensions of the caregiver care ability scale in the intervention group were far better than those of the control group(p<0.001),and the improvement trend was also better than that of the control group(p <0.01).At the same time,the overall health status(GHQ-28)of the quality of life evaluation index was also significantly improved.The improvement of all dimensions and total score of GHQ-28 in the intervention group was better than that of the control group(p<0.001),except for severe depression It is also better than the control group outside the dimensions(p<0.05).At the level of medical care,the level of awareness,acceptance,and satisfaction with the practice model of stroke case management in the intervention group were better than those in the control group(p<0.05);in terms of utilization of medical and health resources,times of return visits,outpatient visits,emergency visits,re-hospitalization,average hospital stay in the intervention group were better than those of the control group,and the difference was statistically significant(p<0.05).2.Results of the second round of action research: In view of the reflections of the first round of action research,such as patients eager to services,print materials slightly insufficient,nurse their professional knowledge and skills shortage,the shortage of nursing human resources and lack of community involvement in management dimension optimization and improvement,to form the final version of the stroke case management model,focus on the mission of stroke material the stroke prevention and control of the ABC development,increasing community door-to-door service,Hcy disease index collection,nurses professional knowledge and skills training and human resources incentive policy revision.Compared with the first round of action research,the results of the second round of action research have increased community participation,and community doctors and nurses have significantly improved their satisfaction,awareness and acceptance of the case management model(p<0.05).Community on-site medical services bring convenience to patients and caregivers,allowing them to experience more care and care,and the professional level of case management nurses and social recognition have also been greatly improved.Conclusions:The treatment and rehabilitation of stroke patients is a long process,patients and their caregivers have continuous needs for disease care knowledge and skills,continuous care management,and social support.The practice model of stroke case management is a multidisciplinary stroke care model led by case management nurses.It provides patients with individualized,continuity of care and disease management,make the patients and their caregivers for disease diagnosis and treatment and care information in time,effectively promote the patients' functional recovery,reduce the incidence of complications and improve rehabilitation process and disease outcomes,promote the overall rehabilitation of stroke patients.At the level of caregivers,it also plays a positive role in improving their care ability and improving their health.At the level of medical and health system,it can effectively improve the doctor-patient,nurse-patient relationship,reduce the medical burden,improve the utilization of medical and health resources,perfect the health service system,and optimize the health service mode.At the level of nursing profession,nursing staff deeply feel their sense of responsibility and value,promote their professional learning and promotion,and ultimately promote the development of nursing profession.The practice model of stroke case management expands the scope of stroke nursing services,effectively extends continuous nursing services,provides reliable professional support and care for the continuous and dynamic treatment,nursing and rehabilitation of stroke patients,and enriches the scope of clinical nursing practice. |
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