Developing Guidelines for Home Visiting of Intermediate Care Patients with the Participation of Families and Community Network

Abstract

This action research aimed to develop and evaluate the guidelines for home visiting middle-term patients with the participation of families and community networks. The home visiting guidelines were developed in collaboration with relevant interdisciplinary teams and community networks using the concepts of Holistic Nursing and Home Visit. The research period was August 2022–September 2023. Quantitative data were analyzed using descriptive statistics, including numbers, percentages, means, and standard deviations. Qualitative data were analyzed using content analysis.

The results of the study found that the developed home visiting guidelines for middle-term patients with the participation of families and community networks consisted of 3 components: 1. Discharge planning linked to the continuous care team in the community                 2.Providing visiting services with the participation of the interdisciplinary team, families, and community networks 3.Determining the roles and responsibilities of the interdisciplinary team, families, and community networks. The evaluation found that after the development, compliance with the home visiting guidelines for middle-term patients increased in all aspects. The self-care skills of middle-term patients and caregivers in the community were at a high level (  = 4.28,  SD = 0.48). Complications in middle-term patients decreased. The urinary tract infection rate decreased from 8.45 %to 1.13 %, pneumonia rate decreased from 11.27 % to 2.25 %, pressure ulcer rate decreased from 2.82 % to 0 %, depression rate decreased from 7.05 % to 0%, and readmit rate decreased from 7.05 % to 2.25 %. From the ADL assessment follow-up at 6 months, it was found that the percentage of middle-stage patients with Barthel ADL index score = 20 increased from 91.55 % to 97.76 %.