With Det Nære Sundhedsvæsen in Region Zealand, we mapped chronic patients' annual check-ups across regional GP practices, including Nærklinik Nakskov, turning findings into targeted follow-up care.

SITUATION​

Det Nære Sundhedsvæsen in Region Zealand operates three GP practices in the southern part of the region. One of them is Nærklinik Nakskov, which ensures that local citizens have a general practitioner nearby. Here, a team of doctors, nurses and secretaries handles everything from routine consultations and prescription renewals to more complex needs, working closely with both the hospitals and the municipality.

For patients with COPD, diabetes and hypertension, the annual check-up is a key moment to follow up on treatment, adjust care plans and support patients in managing their own condition. High-quality follow-up care matters for the patients' health and helps ease the overall load on the healthcare system. The goal was to develop an effective method for assessing and monitoring the quality of these annual check-ups.

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RESULTS

Based on clinical guidelines, we developed a method and mapped the content of annual check-ups for patients with COPD, diabetes, and hypertension. This mapping provided an immediate overview of quality and the reasons for deviations, leading to several targeted efforts, such as increased use of care plans, updates to clinical guidelines, and systematic follow-up.​

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DELIVERABLES

We delivered a mapping of the care programmes and the follow-up care for chronic patients in the local clinics. The work was carried out together with the clinic management and a designated doctor and nurse with special responsibility for optimising patient pathways.

The mapping came with concrete recommendations on planning, follow-up and standardisation, giving the clinics a clear direction for the next steps in their work with chronic care.

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