...
  • 主题
高级搜索  >
历史搜索 清空历史
首页> 外文期刊>International Journal of Integrated Care >Assessment of patient's and health professional's experience of integrated care: preliminary results from a pilot survey in Veneto Region-Italy
【24h】

Assessment of patient's and health professional's experience of integrated care: preliminary results from a pilot survey in Veneto Region-Italy

机译：评估患者和卫生专业人员的综合护理经验：意大利威尼托大区试点调查的初步结果

获取原文
           
页面导航
  • 摘要
  • 著录项
  • 相似文献
  • 相关主题

摘要

Introduction : Population ageing is associated with an increased co-prevalence of chronic diseases. For persons with multimorbidity, care fragmentation may lead to adverse outcomes and patient dissatisfaction while care management programs can improve quality of care. Veneto Region is conducting a pilot experience on integrated care involving persons with Congestive Heart Failure (CHF) and multimorbidity in a primary care setting. The purposes of the present pilot survey were to assess experience of integrated care among patients, general practitioners (GPs) and nurses involved in the project. Methods : Veneto Region Health-Care System is administered through 21 Local Health-Care Authorities (LHAs) which provide Government funded health care granting universal coverage with a per-capita financing system delivering preventive, primary and hospital care. In 2015, Veneto Region started an integrated care-program in the whole region, involving older persons with Congestive Heart Failure (CHF) and multimorbidity. 42 Nurses and 42 GPs received specific training on Care Management using a collaborative team—based approach. The eligibility criteria of patients' selection were “being registered with the participating GPs”, "age 65 years or older" and "with CHF". To target the patients with CHF, co-morbidities and complexity we used the case-finding tool of the Adjusted Clinical Groups (ACG) System that generates high risk case management lists. After obtaining informed consent, the care manager nurse assessed patient needs and preferences, created with GP an evidence-based Care Plan and an Action Plan for patient and care-giver. The nurse then starts a proactive monitoring phase by telephone, in person in the office, or at home. During this contacts, the nurse promotes and supports patients’ self-management, uses motivational interviewing to help patients manage their condition and provides ongoing education resources and general information. The Care Plan is regularly updated by the nurse and the GP and shared with the patient’s other providers to help coordinate complex care.
机译：简介：人口老龄化与慢性病的共患病率增加有关。对于患有多种疾病的人，护理分散可能会导致不良后果和患者不满，而护理管理计划可以提高护理质量。威尼托大区（Veneto Region）正在综合医疗方面开展试点经验，涉及初级保健机构中充血性心力衰竭（CHF）和多发病的患者。本试验调查的目的是评估参与该项目的患者，全科医生和护士的综合护理经验。方法：威尼托大区医疗保健系统通过21个地方医疗机构（LHA）进行管理，这些机构提供政府资助的医疗服务，以人均筹资体系提供全民覆盖，提供预防，初级和医院护理。 2015年，威尼托大区在整个地区启动了一项综合护理计划，涉及充血性心力衰竭（CHF）和多发病的老年人。 42名护士和42名全科医生使用基于团队的协作方法接受了护理管理方面的专门培训。选择患者的资格标准为“已在参与的全科医生中注册”，“ 65岁以上”和“患有瑞士法郎”。为了针对患有CHF，合并症和复杂性的患者，我们使用了可调整临床组（ACG）系统的病例查找工具，该工具可生成高风险病例管理列表。获得知情同意后，护理经理护士会评估患者的需求和偏好，并与GP一起制定基于证据的护理计划和针对患者和护理人员的行动计划。然后，护士可以通过电话，亲自在办公室或在家中开始主动监控阶段。在这种联系中，护士促进并支持患者的自我管理，使用激励性访谈来帮助患者管理病情，并提供持续的教育资源和一般信息。护理计划由护士和全科医生定期更新，并与患者的其他提供者共享，以帮助协调复杂的护理。

著录项

相似文献

  • 外文文献
  • 中文文献
  • 专利
获取原文

客服邮箱：kefu@zhangqiaokeyan.com

京公网安备：11010802029741号 ICP备案号：京ICP备15016152号-6 六维联合信息科技 (北京) 有限公司©版权所有

  • 客服微信

  • 服务号