Intervention description
Dementia, pain
The intervention aims to integrate person-centred and evidence-based APN care for multimorbid patients in general practices in rural areas in Germany. To be eligible for participation, the general practice must confirm its willingness to change some structural and process routines to integrate APN work into its workflow. Examples include providing a treatment room and a car for home visits as well as ensuring weekly case conferences to support APN work.The qualification profile of APNs includes a professional nursing licence, at least two years of professional experience in nursing and an academic degree at the master’s level in a nursing-related program. In addition, APNs complete 500 h of project-specific training.Within the scope of the study, APNs take over the care of multimorbid patients. The integration of APN care for multimorbid patients in practice is a complex intervention [To stabilize the individual health care situation, APNs implement the care process, establish or improve a supportive network and intensify the communication between all those involved in the provision of care. Furthermore, APNs actively involve patients in the care process and specifically promote patient autonomy. Conducting the care process means developing, carrying out, monitoring and evaluating a person-centred and evidence-based care plan.APNs generally begin the care process with an in-depth assessment of cognitive capabilities, nutritional status, pain status, mobility status and psychosocial status. In the first step, cognitive performance is checked with a Dementia Detection test (DemTect) [The initial assessment takes place in the patient's home. Depending on the patient's condition, this initial examination is performed over one or two visits. Due to the patient’s condition and to his or her often reduced mobility, most of the follow-up visits also take place in the patient’s home. If possible, patients are seen at the APN consultation hours, which is held in the rooms of the GP ‘s office. All patients receive a business card with the APN's contact information so they can contact them by phone or email between scheduled visits if needed.Weekly case conferences are scheduled for consultations with the GP. If necessary, short-term consultations are possible at any time. In the regular case conferences, APNs and GPs discuss the health status and the care situation of the participating patients. APNs make suggestions for further treatments, while the GPs decide on the medical procedure. Following German law, the medical side of care is provided under the delegation model.