Family and community nurses

A nurse who leaves the hospital and follows the patient to his home, family, in his daily life, in close collaboration with all
the other professionals involved in the care path, with the aim of intercepting and even preventing his health needs, avoid
unnecessary hospitalizations, encourage de-hospitalization, oversee the effectiveness of therapeutic-care plans, support the
family and in essence improve the quality of life of the person in his / her context of life.

It is present throughout the care continuum

- Health promotion: educational interventions
- Disease prevention: primary, secondary, tertiary
- Activate informal resources (neighborhood, associations, family members ..)
- Environmental assessment (environmental risks)
Case Manager “will help individuals adapt to disease and chronic disability or in times of stress by spending a good part of
their time working at the patients' home and with their families. These nurses will advise on lifestyle and behavioral risk
factors and assist the family in health matters. Through early diagnosis they can guarantee that the health problems of
families are cured when they arise"

Social skills
- Knowledge of the service network
- "with knowledge of public health, social issues and other social agencies, they are able to identify the effects of
socio-economic factors on family health and direct it to the most suitable structures"
- They facilitate early discharge
- They act as intermediaries between the family and the General Practitioner
- Enhance community involvement
- Increase community resources and potential.

The figure of the Family Nurse:

Key professional in primary health, who can make a substantial contribution in promoting health, preventing diseases,
managing chronicity / frailty, playing its role in direct care

Who is the family and community nurse?

- At the basis of the new concept of family nurse is the combination of some fundamental elements:
- The particular interest in families (basic core of society)
- The home as an environment (biophysical and psychosocial operational setting)
- Family members can take care of health problems together (activate resources in the family)

Secondary prevention
- Promote screening and vaccination programs
- Activate appropriate measures to minimize the impact of health problems on the individual and his family It has a
connecting role in the service network
Tertiary prevention
He is involved in the rehabilitation and reconstruction of defensive and protective resources of the family and its network.
Moreover, he is involved in direct assistance, works to obtain, as appropriate, care, support, rehabilitation, palliation,
accompaniment to death.
- Help family / individuals adapt to chronic disease and disability
- Helps to reduce the phenomenon of BURN-OUT
- Knows the offer of social and health services in the area: adequate responses
- Provides technical-scientific knowledge and relational knowledge
- Detects obvious and non-obvious needs
- Supports the family in making choices, proposing viable solutions
- Facilitates early hospital discharge
- Acts as a link between the family and the General Practitioner

Community nurse's surgery

Manages NON-complicated chronicity (stable patients): help in self-management of the disease
1
Periodic monitoring of clinical parameters
Interception of healthy people for various types of screening: oncology / risk of chronic socially relevant diseases

The family nurses

- Outpatient activity
- Continuity of care during the night / holidays / pre-holidays ........ Nursing guard (avoid improper access to the
emergency room)
- Active collaboration and integration with all health professions: work in synergy!
- Particular attention to end-of-life care / palliative care
- Nurse responsible for the care project
- Self-employed nurse in the prescription of various aids such as:
- Anti-decubitus mattresses / pillows
- Advanced medicine
- Absorbent aids

FAMILY NURSE: WHY?

- Studies show a reduction in overhead costs
- Decrease in hospital admissions
- Decreased exacerbation of chronic diseases
- Reduction of falls in the elderly
- More adherence to therapy

Empowerment of the patient

The National Chronicity Plan of July 2016 underlines the usefulness of "educating the patient to one conscious self-
management of diseases and care path ". One of the most concise and clear definitions of the word empowerment is by
community psychologist Julien Rappaport: "It is the process by which people they achieve mastery of their lives » Others
have called empowerment "a process educational aimed at helping the patient to develop the knowledge, skills, attitudes and
degree of awareness needed to take responsibility in decisions that affect your health » Patient Empowerment is a strategy I
go through health education and the promotion of behavior conducive to health, provides the person with the critical tools to
make better decisions for their well-being by reducing cultural and social inequalities. It is a sort of "information therapy"
that tends to level out knowledge between doctor and patient.
Family medicine like is evidenced by international and national scientific studies, it represents the most suitable setting to
increase the patient awareness of the disease and act positively.
 Practical meetings for healthy eating
 Group walks for physical activity
 Weekly meetings to share the lived daily

The benefits of patient Empowerment:

- a patient at the center of his / her health and care process care, feels empowered, included in the processes
decision-makers, he feels stronger on the scene;
- is a patient who is capable of increasing his / her own compliance with the proposed therapies;
- increases the sense of responsibility in using the services health;
- a conscious and informed patient knows how to prevent them most common diseases resulting from incorrect
behavior and he also knows how to manage himself in the treatment process.