Data Driven Essential Care in District Nursing: improving patient outcomes and maintaining independence

The demand for home care is predicted to rapidly increase in the next decade, due to an aging population and increase in people with multimorbidity. Therefore, the need for effective and efficient district nursing strategies is growing. For many older adults, maintaining independent and living at home as long as possible is of paramount importance. District nurses play a key role in supporting these personal goals, by managing long-term conditions, preventing and treating acute illnesses and promoting self-management. However, adequate insight into the extent, nature and outcomes regarding district nursing interventions to support patients’ personal goals on independence are missing. The large-scale collection of health information in district nursing offers great potential to measure, direct and improve clinical practice. And in particular, to support patients and district nursing teams in their communal ambition to facilitate a society in which people can live independently at home for as long as possible. Yet, few district nursing organizations have started using health data from the electronic nursing record for this purpose. Clear directions to use health data from the electronic nursing record such as OMAHA, are lacking. To learn from and improve practice and patient outcomes, a learning health care system in district nursing care is needed. Therefore, the overall objective of this proposal is to develop a learning health care system in district nursing and use this intervention strategy to improve independence in older adults receiving district nursing. The intervention strategy will be developed in co-creation with patients, informal caregivers, district nurses, data scientists and educators to ensure that the intervention strategy is person-centered and fit the needs of patients and district nursing teams. Furthermore, our goal is to strengthen the scientific- and knowledge infrastructure in district nursing care by strengthening the collaboration between practice, science and education and create dual positions for district nurses in which they work in clinical practice and on their PhD. The Medical Research Council framework for the evaluation of complex interventions will be used for developing and testing the intervention strategy. Our proposal consists of five work packages. 1. WP1 starts with the exploration of older peoples’ goals and potential district nursing strategies to promote independence by assessing literature and current practice in district nursing care. This work package yields insight into the overarching goals of clients on independence, effective nursing interventions and the way in which nursing professionals register problems, goals and outcomes relating to independence in the electronic nursing record. 2. WP2 is dedicated to assessing current data that are available in the electronic nursing record (ENR) as well as prerequisites for usage of data to create a learning health system process. This work package yields an information standard consisting of a collection of agreements and insights on barriers and facilitators that must ensure that healthcare information on independence can be registered, made accessible and used with the correct quality and in a meaningful way. Furthermore, this work package will result in a prototype dashboard that can be built in the electronic nursing record (ENR) of district nursing care organizations. 3. In WP3 we investigate how systematically collected data can improve goal based shared decision making with older adults to reach interventions that support patient outcomes such as maintaining independence. This work package focuses on training the professionals in clinical practice. 4. In WP4 we are bringing the learning health care system to practice and perform a pilot feasibility study in which 20 teams will be working with data on independence and continuously improve daily practice. The teams will be trained in effective strategies to promote independence, in goal-based decision making and will be using the data in the ENR to monitor independence, promote shared decision making and initiate effective interventions. We will monitor on process (how are data used, does it lead to alignment in interventions, does it support patients) and outcomes (independence, quality of life, cost-effectiveness). 5. In the final work package (WP5), we disseminate the deliverables and lessons learned on regional, national and international level. A strong project team with national and international partners are involved to gain maximum impact. Actions will be performed to disseminate the findings on the level of clinical practice, education and science. We will build a network on the topic of a learning health care system in district nursing care to further strengthening the district nursing infrastructure.