SINDEFI-SEP Network, France
E-mail: [email protected]www.sindefi.org
Whether a hospital nurse, an independent nurse, or a nurse working within a network, nurses work on a daily basis with other members of the care and social team around the patient, as well as with the patient’s family circle. For a coordinating nurse, collaboration with all the professionals involved is essential and pivotal.
Quite a number of professionals tend to a patient suffering from multiple sclerosis: nurses, neurologists, attending practitioners, physiotherapists, ergotherapists, social assistants, psychologists, all intervening according to various and complex symptoms. Interaction between these professionals is not always apparent.
Mission of the Coordinating Nurse
The SINDEFI-SEP network (multiple sclerosis and inflammatory diseases of the nervous system) was born from a need for communication around the patient aimed at improving the quality and accessibility of care. Financed by public funds, it has been in existence for three years and is led by a coordination team composed of a doctor, a nurse, a psychologist and a secretary. It enables communication, around a common charter, between neurologists (all types included) and other medical and paramedical representatives from the departments of Val-de-Marne, Seine-et-Marne and Essonne. One of its roles is to facilitate communication between the local authority and the hospital.
Contribution of Home Visits
When hospitalised, the patient cannot be evaluated within the context of his normal life. Home visits offer tools for optimising care. They can be carried out jointly with other professionals (e.g. ergotherapists, social assistants, home helps, attending practitioners).
A patient with multiple sclerosis is hospitalised at different moments of his illness: the announcement of the diagnosis, the setting up of treatment, attacks, and entering the progressive phase of the illness. The interventions of the coordinating nurse in the department (of neurology, most frequently) take place in agreement with the head of the department by convention, upon request from a hospital professional, or at the time of hospitalisation, known within the network.
The coordinating nurse intervenes in different situations:
_With nurses from inpatient or outpatient clinics: for example, at the time of setting up injectable treatment. If the nurses in the department think that a patient needs closer followup at home, they can contact the coordinating nurse who will be able to carry out a follow-up visit, or even contact and train an independent nurse to help the patient.
_With executive nurses: the coordinating nurse can be ask to participate in the programming of hospitalisation in conjunction with the network doctor, when the neurologist or attending practitioner decides that hospitalisation is necessary. By working together with the doctor, the nurse can either avoid duplicating tests or carry out additional tests (e.g. vesical ultra sound for evaluation of residue). Furthermore, the nurse knows the daily requirements of the patient and can see to it that these are taken into account during hospitalisation.
_In the context of returning home, the coordinating nurse directs the patient towards a healthcare professional close to home, if necessary, thanks to the directory of profession als set up by the network: nurses, physiotherapists or home helps. For all these actions, they rely upon the information gathered by the carers at the time of hospitalisation, in agreement with the patient.
_With patients: the coordinating nurse delivers adapted, up-to-date information, additional to that given by the doctor and the hospital, possibly relying on specific booklets.
_The network can also be contacted directly by the hospital for the setting up of human and/or technical aids (e.g. for a patient in a wheelchair). The coordinating nurse knows the pathology and can bring his/her expertise with regard to the type of help that needs to be set up.
_One of the care projects set up by the SINDE FI-SEP network is an alternative to hospitalisation: corticoid perfusions at home at the time of an attack. The coordinating nurse helps to set it up, reminding the hospital doctors of the existence of this possibility, and facilitates its setting up through the provision of practical procedures.
In order for this organisation to function correctly, two points are essential: the training of hospital and independent carers at the SEP, so as to constitute a directory of resources of trained professionals, as well as regular information from the hospital teams on the existence and the role of the health network.
Advantages of the Concept
The SINDEFI-SEP network was financed for the first three years (2003-2006) by FAQSV (Funds for Assistance in the Quality of Care in Cities) granted by URCAM (Regional Union of Sickness Insurance Funds). For the period 2007-2010, the network is financed by the DRDR (Regional Grant for the Development of Networks), awarded by URCAM and the ARH (Regional Hospitalisation Agency). The budget has not yet been defined, but will be in the region of 450 000 per year.
An external evaluation was carried out at the end of 2006 and made it possible to put forward the advantages brought about by the network to patients and professional members of the network (independent and hospital). The main results are:
_Better patient information.
_Improvement in the coordination of care, allowing reduced isolation of the various professionals and, in particular, general practitioners and allowing a faster response to the problems of responsibility for care, particularly at home.
_An alternative to hospitalisation, particularly thanks to corticoid perfusions at home, but due to a better functioning of the network of professionals of proximity. The savings made (for sickness insurance) by corticoid perfusions at home versus at the hospital were estimated to be approximately 230 000 for 80 courses of treatment, considering the price per day in hospital and the average cost of a journey by ambulance in the areas covered by the network.
_The growing capacity of paramedical professionals (at least, the physiotherapist) in responding to the various questions posed by patients.
In conclusion, one can see the value of the intervention of the network nurse, both for patients and healthcare professionals. By having a better knowledge of patients’ usual environment and their home carers, the coordinating nurse is able to optimise care, closer to patients’ real needs, and adapt to their pathology. Hospital’s carers appreciate the more personalised information provided thanks to the home visit reports. As for the extra hospital structures, they are extremely interested in the nurse’s expertise of the pathology concerned, and call for relays of this kind.
On their side, hospitalised patients who meet the nurse feel supported and are reassured by the existence of a link between their daily life and this passage to the hospital. We now know that a wellsurrounded patient will be able to better confront the disease and its constraints, and will be more observant of his treatment.