Authors

Anna Capsada Juanola

Position

Diplomada en Enfermería.

Contact address

Avda. Jaume I, nº 63. 08272 Sant Fruitós de Bages, Barcelona

Abstract

This article describes the work of a multi-disciplinary team (MDT) using the clinical system for Case Management of Chronic Obstructive Pulmonary Disease (COPD).

We have applied to this group of patients a system that facilitates the movement of the patient/family through the levels of the health care system in accord with the severity/stage of their illness, while, at the same time, involving them in the process through patient education and co-responsibility for therapy.

The results after 2 years of application demonstrate an increase in effectiveness in the management of this illness, as evidenced by a reduction in re-admissions and the average inpatient stay.

Co-ordination between health care providers makes communication more agile, guarantees compliance with education and increases the satisfaction of patient and family.

Keywords:

Case Management; multi-disciplinary team; education; COPD

Versión en Español

Título:

La Gestión de casos para el manejo de enfermos con Patología Respiratoria Crónica