Vernetzte Betreuung von Patientinnen und Patienten mit Herzinsuffizienz

2011 ◽  
Vol 68 (2) ◽  
pp. 113-118 ◽  
Author(s):  
Cornelia Bläuer ◽  
Otmar Pfister ◽  
Christa Bächtold ◽  
Therese Junker ◽  
Rebecca Spirig

Patienten mit Herzinsuffizienz (HI) sind in ihrer Lebensqualität stark eingeschränkt, haben eine schlechte Prognose und müssen häufig hospitalisiert werden. Die Forschung hat gezeigt, dass die Gesundheitsresultate dieser Patientengruppe durch ein gutes Selbstmanagement verbessert werden können. Eine Möglichkeit zur Verbesserung des Selbstmanagements sind ambulante Diseasemangementprogramme, welche die Lebensqualität verbessern und Kosten reduzieren helfen. Solchen Programmen liegt meist das von der WHO entwickelte Chronic Care Model zu Grunde, welches auf die Betreuung chronisch Kranker mit einem hohen Selbstmanagementbedarf ausgerichtet ist. Um ein gutes Selbstmanagement entwickeln zu können braucht es bedürfnissorientierte Patientenschulung und -beratung, denn die Betroffenen benötigen nicht nur Wissen zur Krankheit sondern müssen handlungsfähig werden. In der Schweiz fehlt es an etablierten Modellen und Programmen zur Betreuung von chronisch Kranken, insbesondere HI-Betroffenen. Aus diesem Grund hat eine schweizerische Expertengruppe für HI eine Modell zur „vernetzten Betreuung“ erstellt. In Anlehnung daran bietet die Schweizerische Herzstiftung seit 2009 ein Schulungsprogramm zur Unterstützung von Ärzten, Betroffenen und deren Angehörige an. Eine erste Evaluation hat unterschiedliche Resultate von Seiten der Ärzte gezeigt. Von den Betroffenen waren die Rückmeldungen äußerst positiv. Sie beurteilten die Schulungen als bedürfnissorientiert und unterstützend. (Geschlechtsbestimmende Begriffe stehen immer stellvertretend für beide Geschlechter)

2013 ◽  
Vol 35 (2) ◽  
Author(s):  
A. Thomas McLellan ◽  
Joanna L. Starrels ◽  
Betty Tai ◽  
Adam J. Gordon ◽  
Richard Brown ◽  
...  

2016 ◽  
Vol 50 (2) ◽  
pp. 239-246 ◽  
Author(s):  
Daiane Medeiros da Silva ◽  
Hérika Brito Gomes de Farias ◽  
Tereza Cristina Scatena Villa ◽  
Lenilde Duarte de Sá ◽  
Maria Eugênia Firmino Brunello ◽  
...  

Abstract OBJECTIVE: To analyze the care provided to tuberculosis cases in primary health care services according to the elements of the Chronic Care Model. METHOD: Cross-sectional study conducted in a capital city of the northeastern region of Brazil involving 83 Family Health Strategy professionals.A structured tool adapted to tuberculosis-related care in Brazil was applied.Analysis was based on the development of indicators with capacity to produce care varying between limited and optimum. RESULTS: The organization of care for tuberculosis and supported self-care presented reasonable capacity.In the coordination with the community, the presence of the community agent presented optimum capacity.Partnership with organizations of the community and involvement of experts presented limited capacity.The qualification of professionals, the system for scheduling and monitoring tuberculosis in the community, and the clinical information system presented basic capacity. CONCLUSION: The capacity of the primary health care services to produce tuberculosis-related care according to the elements of the Chronic Care Model is still limited.Overcoming the fragmentation of care and prioritizing a systemic operation between actions and services of the health care network remains as a major challenge.


Curationis ◽  
2017 ◽  
Vol 40 (1) ◽  
Author(s):  
Ozayr H. Mahomed ◽  
Shaidah Asmall

Background: An integrated chronic disease management model has been implemented across primary healthcare clinics in order to transform the delivery of services for patients with chronic diseases. The sustainability and rapid scale-up of the model is dependent on positive staff perceptions and experiences.Objectives: The aim of the study was to determine the perceptions and experiences of professional nurses with the integrated chronic care model that has been implemented.Method: A cross-sectional descriptive survey utilising a self-administered questionnaire was conducted amongst all professional nurses who were involved in delivering primary healthcare services at the 42 implementing facilities in September 2014. Each facility has between four and eight professional nurses providing a service daily at the facilitiesResults: A total of 264 professional nurses participated in the survey. Prior to the implementation, 34% (91) of the staff perceived the model to be an added programme, whilst 36% (96) of the staff experienced an increased workload. Staff noted an improved process of care, better level of interaction with patients, improved level of knowledge and better teamwork coupled with an improved level of satisfaction with the work environment at the clinic after implementation of the integrated chronic disease model.Conclusion: Professional nurses have a positive experience with the implementation of the integrated chronic disease management model.


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