NÆRKLINK NAKSKOV, REGION ZEALAND
We assisted the Det Nære Sundhedsvæsen in improving follow-up care for patients with chronic illnesses in regionally managed GP practices.
SITUATION
The Local Health Service operates three GP practices in the southern part of Region Zealand. The quality of follow-up care for patients with chronic conditions is critical for their health and for reducing the overall strain on the healthcare system. Therefore, it was necessary to develop an effective method to assess and monitor the quality of annual check-ups.
RESULTS
Based on clinical guidelines, we developed a method and mapped out the content of annual check-ups for patients with COPD, Diabetes, and Hypertension. This mapping provided an immediate overview of quality and the reasons for deviations, which led to several targeted efforts, including increased use of care plans, updates to clinical guidelines, and systematic follow-up.
DELIVERABLES
As a basis for improvement efforts, we provided a mapping of the quality of care programmes and the follow-up care for chronic patients in local clinics, along with specific knowledge and recommendations for improvements, including concrete recommendations regarding planning, follow-up, and standardisation.
OUR ROLE
We developed the method, conducted medical assessments of the data, and provided analysis and recommendations for targeted actions to improve follow-up care for patients with chronic illnesses.