Klemenc-Ketis Zalika, Benkovič Robertina, Poplas-Susič Antonija
a Ljubljana Community Health Centre , Ljubljana , Slovenia.
b Department of Family Medicine, Faculty of Medicine , University of Maribor , Maribor , Slovenia.
J Community Health Nurs. 2019 Jul-Sep;36(3):139-146. doi: 10.1080/07370016.2019.1630996.
Patients that cannot come to their family medicine practice (i.e. who have difficulties with access) do not receive the same preventive screening activities and management of their chronic diseases as those who can. Community nurses who provide healthcare to patients in their homes were trained in additional competencies, including screening for risk factors for selected diseases and the management of patients with selected chronic diseases. The presented model enables equal management of all registered patients, regardless of accessibility. It also fosters exchange of information within the team members and thus improves the quality of the team management of patients.
无法前往家庭医疗诊所就诊的患者（即就医存在困难的患者）无法像能够前往诊所的患者那样接受相同的预防性筛查活动和慢性病管理。为在家中接受医疗服务的患者提供护理的社区护士接受了额外的技能培训，包括对特定疾病风险因素的筛查以及对特定慢性病患者的管理。所提出的模式能够对所有登记患者进行平等管理，而不论其就医的难易程度。它还促进了团队成员之间的信息交流，从而提高了患者团队管理的质量。
