医院-社区-家庭-个人四位一体的个案管理模式对心力衰竭患者生存质量的影响

目的 探讨医院-社区-家庭-个人四位一体的管理模式对心力衰竭患者生存质量的影响。方法 选取2018年1-6月心血管内科收治的80例心力衰竭患者为研究对象,其中 2018年1-3月收治的34例心力衰竭患者设为对照组,采用常规护理管理,2018年4-6月收治的46例心力衰竭患者设为观察组,采用个案管理模式进行管理,以时间为节点组建住院期间基于医院的个案管理师团队、准备出院时从医院到社区的个案管理师团队、出院后基于社区的个案管理师团队,为患者提供医院-社区-家庭-个人四位一体的连续个案管理。比较2组患者生活质量、再入院率。结果 干预12个月后,观察组患者生活质量得分高于对照组(t=3.372,P=0.001),出院后6个月及12个月患者的再入院率均低于对照组(χ²=4.809,P=0.028;χ²=4.581,P=0.032)。结论 医院-社区-家庭-个人四位一体的连续个案管理模式可以有效提高心力衰竭患者的生存质量,降低患者再入院率。

Effects of hospital-community-family-individual case management model on the life quality of patients with heart failure

Objective To explore the effect of hospital-community-family-individual case management model on the life quality of patients with heart failure. Methods Totally 80 heart failure patients admitted to the department of cardiovascular medicine between January and June 2018 were selected. Among them, 34 patients admitted in the first 3 months were selected into the control group, given routine nursing, while the rest 46 patients were chosen into the observation group, provided with the case management. A case management team was set up including a hospital-based case management team during hospitalization, one for discharge and another one based on the community, so as to implement hospital-community-family-individual continuous case management. The life quality and readmission rate of the 2 groups were evaluated and compared. Results One year after the intervention, the life quality of the observation group was significantly higher than that of the control group(t=3.372, P=0.001), while the readmission rate at 6 and 12 months after discharge were significantly lower than those of the control group (χ²=4.809, P=0.028;χ²=4.581, P=0.032). Conclusion The hospital-community-family-individual continuous case management can effectively improve the life quality of patients with heart failure and reduce their rate of readmission.