Table 2 Description of models of care

50% Professional Development Nurse

50% Direct patient care

Municipality A

Elderly patients who are in acute deterioration and new patients, including those coming from other healthcare levels (hospitals, nursing homes, etc.).

Clinical evaluation of target population, coordination and planning of offered services.

Internal training of the staff, a resource person for the unit and responsible for the district’s dementia care team

1 AGN

Colocation with district home nursing service. Delivery of direct patient care at patient’s home or nursing home.

Report to the district leader, hierarchically over staff nurses.

Nursing Policlinic

Municipality B

Patients with type II diabetes, chronic obstructive pulmonary disease (COPD), urine incontinence and wound management needs.

Users initiating contact were offered guidance about the available services. Routine control of type II diabetes and COPD patients. Assistance with wound management. Advice and guidance for incontinence. Two different service ‘packages’ for diabetes and COPD after referral by GP.

Regular internal training and supervision and informal training of colleagues.

1 AGN

Located at the local health centre (Helsehus). Users visit the policlinic.

Nursing Policlinic belonged to the municipality’s Home Services Unit. Home nursing work groups belonged to the same unit.

Response Team

Municipality B

Patients with dementia or other cognitive problems, weight loss, low physical activity and increased risk of falls.

Mapping and evaluation of target population.

Regular internal training activities. Supervision and informal training of colleagues.

2 AGNs

3–4 RNs

1 Physiotherapist

Colocation with home nursing services. Direct patient care through home visits

Response Team belonged to Home Services Unit and was a parallel structure to the four home nursing work groups. The Response Team was an extra resource for these work groups.

Virtual Ward

Municipality C

Patients over 65 years old with a hospitalisation that needs to be followed up by home services. Three diagnoses affecting function, with capacity to consent. No mental or addiction diagnoses.

Home visit by AGN after the discharge. AGN collects medical history and a medication list. AGN uses systematic clinical examination, and when relevant, blood, urine and bacterial culture tests. Follow-up visit by AGN up to 14 days later if deemed necessary. Physiotherapist also visits and evaluates patient. Creation of care plan by AGN, home nurse and physiotherapist, which is forwarded to GP.

The medical advisor held relevant lectures for the Home Nursing personnel.

1 AGN

1 Physiotherapist

1 Medical advisor

Later adaptation included a GP

Colocation with home nursing services. Direct patient care through home visits.

Report to the manager of home based services. Virtual Ward was a parallel structure to 2 Home Nursing groups.

Quality Coordinator

Municipality D

Elderly patients with multiple diagnoses and multiple medications.

Systematic examination, systematic evaluation tools and discussion with patients and informal caregivers. Prioritisation of patient’s problems and creation of care plan. Examples of measures are fluid-intake monitoring, blood pressure monitoring or referral of patient to Emergency Department or hospital.

Quality surveillance and improvement, the internal training and supervision of personnel and the handling of deviations (tilsynssaker).

1 AGN

Colocation with home nursing services and nursing home. Direct patient care through home visits or nursing home visits.

The AGN is reporting to the manager of the Department for Service Allocation, Development and Innovation. Home nursing and nursing home are different departments at the same level.

Only direct patient care

Municipality E

Undiagnosed patients or patients with complications living at home or at the nursing home

Systematic physical and psychosocial evaluation of the patient, documentation of findings, creation of care plan.

No other formal functions.

1 AGN

First colocation with municipality’s administrative services. Eventually, colocation with home nursing services and GP’s office. Direct patient care through home visits or nursing home visits.

The AGN is reporting to the chief municipal officer for Healthcare Services. The Unit for Home Nursing and the two nursing homes also belong to Healthcare Services.