Primary patients in a nursing home.

Formerly a "primary nurse," I always wished to practice that concept where I work-in a nursing home. Because of the number of patients that a nurse must manage in a nursing home, the concept was impossible; but a similar concept using a monitoring system can be used. That, which our longterm-care facility (of which I am director of nursing) practices, can be referred to as having "primary patients." We actually cannot give the total care as primary nurses do in hospitals; however, with our primary patients, we still can utilize the nursing process, supervise, and collaborate services for a specific number of individual patients.

In nursing homes, patients receive care from numerous staff members. One may pass meds, another may do treatments, and still another may provide for the patients' basic needs. The list can go on. By having primary patients, each nurse has the responsibility for planning and seeing to the delivery of care to their assigned patients over 24 hours, as well as on a long-term basis. With a small number of patients to ensure that, the nurse easily assumes accountability for monitoring and supervision, as well as the development of patient outcomes.

Every nurse on staff participates, including administrative nurses, staff nurses, and part-time nurses. With all nurses taking part, we are making the best efficient use of staff and their abilities. In our facility, the nurses have only seven or eight primary patients,

Initially, each nurse is assigned, in each wing of the facility, to a different type of patient (different care levels), ranging from alert, walking-type patients to comatose-bed-type patients. That allows the nurse to have a variety of patients. The nurse then follows her patient until the patient leaves the facility. When a patient is transferred, the nurse will take the next new admit - unless her patient is transferred to a hospital for only a temporary stay. Then the nurse keeps the same patient upon readmission. The patient's nurse is identified on the front of the chart where the patient's name is labeled; the nurse's initials are added.

The primary patient process utilizes a form called the Quality Care Questionnaire (QCQ). The nurse must "actively participate" in seeking out information from all areas of the patient's records, as well as make checks and observations of the patient and communicating with the staff. The QCQ is designed for quick, easy answers-to save time-rather than requiring written summaries. On the QCQ, the nurse simply checks off one word or gives a brief answer.

The QCQ is an assessment tool that relates directly to the utilization and necessary information required by all health-care organizations: (1) collecting data (assessment); making nursing diagnosis; (3) writing a plan to deal with a patient's specific problems and needs, with measurable goals; (4) implementation/intervention; and (5) evaluation of the plan.

The nurses become possessive with their primary patients, which creates an increase in accountability. That is seen in improved paperwork that satisfies annual state inspections. The nursing and other departments respect reports prepared by the individual nurse for her primary patient. For example, if a nurse posts a note to increase her patient's ambulation, the floor nurse will support that request. The nurses also are fortunate to have support of the physician. If a nurse questions medication changes or follow-up or lab work, ...