OBJECTIVE

To examine community nursing services for patients with cardiovascular diseases, chronic respiratory diseases and other general medical conditions, making the transition from hospital to home.

DESIGN

The original study design was a randomised controlled trial. This study is a secondary analysis of the hospital records documented by community nurses for the study-group patients.

SAMPLE

The sample consisted of 46 subjects, randomly drawn from the main study group of the study.

MEASUREMENTS

The community nursing records were analysed using the Omaha System. Self-reported health status and readmission data were retrieved from the data base of the original study.

RESULTS

The three groups of patients experienced problems across the four domains in the Omaha System. Community nursing interventions did not differ greatly by disease groups. The primary purpose of home visits was observation, followed by treatment and procedures and health teaching. The community nurses in the study spent more effort providing health teaching to the respiratory group than to their counterparts. The outcome measures are self-reported health status and hospital readmission rates. For self-reported health status, significant differences were observed in the respiratory and cardiovascular group before and after community nursing services. For hospital readmission rate, no significant difference was found.

CONCLUSIONS

To improve the well being of chronically ill patients, a comprehensive home intervention programme, emphasising continuous needs of monitoring and case management, is fundamental to producing desired, measurable effects.

RELEVANCE TO CLINICAL PRACTICE

This paper adds the understanding of home-care services provided by community nurses to chronically ill patients. The scope of nursing services emphasises the significance of a positive, patient-centred, caring and appropriate client-practitioner relationship to improve the self-reported health of patients.