Telephone-based, nursing follow-up of patients with heart failure
Section: Hands on
How to quote
Padilla Just MN et ál. Seguimiento telefónico enfermero a pacientes con insuficiencia cardiaca. Metas de Enferm abr 2011; 14(3): 22-26
Authors
María Neus Padilla Just, Núria Ros del Hoyo, Àngels Raventós Castany, Vanessa Escribano Rueda, Cristina Luengo Cascud
Position
Enfermera del Centro de Seguimiento de Enfermedades Crónicas. Instituto Catalán de la Salud.
Contact address
María Neus Padilla Just. C/ Manso, 19, planta 7ª. 08015 Barcelona.
Contact email: mnpadillaj@gencat.cat
Abstract
The growth of the population afflicted by chronic disease has increased healthcare demand. In order to address this situation, the Catalan Institute of Health launched the “Centre for Follow-Up of Chronic Diseases” (CSMC from its acronym in spanish) in the health area of Barcelona on 2006.
The aim of this centre is to promote self-care, to empower the patient and to give remote healthcare assistance.
The CSMC is a proactive telephone-based nursing follow-up system that provides care to patients with Heart Failure (HF) in a cross-sectional manner between Primary Care (PC) and Hospital Care (HC) by sharing the clinical history in electronic format, which includes the nursing process and language. Patients’ knowledge, skills and motivation are developed at the centre.
Since its beginnings, it has covered 1.400 patients whose mean age is 78 years and the majority of whom are in functional class 2-3, according to the New York Heart Association (NYHA).
Positive trends have been observed in self-care, pharmacological compliance, adherence to weight self-management and increased antipneumococcal vaccine coverage.
Telephone-based care is a useful strategy for the shared management of the outpatient follow-up of chronic patients, and can be extrapolated to patients with other chronic diseases.
The aim of this centre is to promote self-care, to empower the patient and to give remote healthcare assistance.
The CSMC is a proactive telephone-based nursing follow-up system that provides care to patients with Heart Failure (HF) in a cross-sectional manner between Primary Care (PC) and Hospital Care (HC) by sharing the clinical history in electronic format, which includes the nursing process and language. Patients’ knowledge, skills and motivation are developed at the centre.
Since its beginnings, it has covered 1.400 patients whose mean age is 78 years and the majority of whom are in functional class 2-3, according to the New York Heart Association (NYHA).
Positive trends have been observed in self-care, pharmacological compliance, adherence to weight self-management and increased antipneumococcal vaccine coverage.
Telephone-based care is a useful strategy for the shared management of the outpatient follow-up of chronic patients, and can be extrapolated to patients with other chronic diseases.
Keywords:
disease management; health education; nursing; pharmacological compilance; self-careTelephone-base follow-up
Versión en Español
Título:
Seguimiento telefónico enfermero a pacientes con insuficiencia cardiaca
