Abstract
This study aims to clarify those needs of intractable illness that involve public health nurses and to systematically put in order the developing process of care management for those cases. We used a researching method of personal interviews with thirteen expert public health nurses involved in an inveterate case, asking questions in detail about care management processes. Care management process activity indices were used in the analysis framework in order to read situations, needs and processes by units of activities taken by the public health nurses with their own words. As a result, ten categories have been extracted as needs concerning the betterment of relevant medical care, assistance to user's home care and daily living, improvement of home care environments and overall extended care management. Public health nurse processes are featured by starting with interview on application for public aid for medical expenses, taking action on the subjects, their family members, specialist doctors, neighborhood doctors, and care-team members. Also included were individual interrelations so that services will best fit the needs, while anticipating the future situations from early phases, flexibly and timely arranging the existing services (medical care, health care, welfare etc. whether public or non-public), taking action to improve the regime of related institutions. In particular, the features include, among others, securing the breath of life and driving spirit, arrangement of an environment that utilizes remaining functions and reduces caring load, maintenance of emergency response, use of hospitals for short-stay purposes, talking to doctors for patients, working as an interpreter, effecting liaison with inveterate disease caring businesses, and assistance to care team members.
