What Works In Chronic Care Management: The Case Of Heart Failure

Sochalski, Julie; Jaarsma, Tiny; Krumholz, Harlan M.; Laramee, Ann S.; McMurray, John J.V.; Naylor, Mary D.; Rich, Michael W.; Riegel, Bárbara; Stewart, Simon

doi:10.1377/hlthaff.28.1.179

Cited by 217 publications

(160 citation statements)

References 9 publications

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“…31 It is critical that the AHW feels supported, respected in their role and informed and competent with respect to relevant health information. Further, with research suggesting patients enrolled in programs using multidisciplinary teams will have significantly fewer hospital readmissions than routine care patients, 32 inclusion of the AHW in patient team management is critical. Such suitable acknowledgement within the hospital hierarchy is also likely to improve role effectiveness and has significant implications for staff retention.…”

Section: Recommendations For Improving the Ahw Role In Hospitalsmentioning

confidence: 99%

Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology

Taylor

Thompson

Smith³

et al. 2009

Aust. Health Review

112

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To enhance Aboriginal inpatient care and improve outpatient cardiac rehabilitation utilisation, a tertiary hospital in Western Australia recruited an Aboriginal Health Worker (AHW). Interviews were undertaken with the cardiology AHW, other hospital staff including another AHW, and recent Aboriginal cardiac patients to assess the impact of this position. The impact of the AHW included facilitating culturally appropriate care, bridging communication divides, reducing discharges against medical advice, providing cultural education, increasing inpatient contact time, improving follow-up practices and enhancing patient referral linkages. Challenges included poor job role definition, clinical restrictions and limitations in AHW training for hospital settings. This study demonstrates that AHWs can have significant impacts on Aboriginal cardiac inpatient experiences and outpatient care. Although this study was undertaken in cardiology, the lessons are transferable CARDIOVASCULAR DISEASE (CVD) is the leading cause of mortality in Aboriginal Australians,* and is responsible for contributing to high rates of Aboriginal hospitalisation. 1,2 Compared with other Australians, Aboriginal people have three times the rate of coronary events and more than twice the inhospital coronary heart disease death rate. 2 Cardiac rehabilitation (CR) is an organised approach to secondary prevention and cardiac care involving exercise, risk reduction, behavioural modification and education.

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Section: Recommendations For Improving the Ahw Role In Hospitalsmentioning

confidence: 99%

Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology

Taylor

Thompson

Smith³

et al. 2009

Aust. Health Review

112

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“…Studies showed that the elderly often had multiple diseases, which could cause limitation and dependence. (4) In this sense, it should be emphasized that health professionals must be prepared to assist the elderly in the organization of their care, with services that must be varied to meet their multiple needs. It is important to build networks of elderly care.…”

Section: Discussionmentioning

confidence: 99%

“…(1)(2)(3) In the last two decades, some researchers have conducted studies in order to identify aggravating factors in the health/disease status of the hospitalized patients, to improve the quality of care provided to them and also to reduce costs. (4)(5)(6) In this context, one of the proposals that can be a tool to improve communication within the interdisciplinary team, and to characterize the complexity of care for clinical, scientific and educational purposes, is the Interdisciplinary Medicine Instrument (INTERMED): a tool that can offer positive responses in assessing patients requiring care, and in helping adjust the provision of health services in general, and in mental health. (7) The validity of this instrument is documented for the care of several types of patients.…”

Section: Introductionmentioning

confidence: 99%

Biopsychosocial aspects and the complexity of care of hospitalized elderly

Gutierrez

Silva

Shimizu³

2014

Acta paul. enferm.

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Objective: To investigate the biopsychosocial aspects and aspects of the health system of hospitalized elderly and to classify their degree of care complexity. Methods: This was a quantitative study whose convenience sample consisted of 279 elderly. The Interdisciplinary Medicine Instrument (INTERMED) method was used, a tool that identified biopsychosocial aspects and conditions of the health system and classified the complexity of the patient. The data were submitted to descriptive analysis. Results: The prevailing profile was of elderly women, retired, white, with low educational levels, married and satisfied with their life conditions. The mean age was 72.3 years. The biological domain was the most compromised. As for the complexity of care, 34.8% of the patients required multiprofessional care. Conclusion: The elderly had high care complexity, with the biological and health system domains being the most compromised. ResumoObjetivos: Conhecer os aspectos biopsicossociais e as condições do sistema de saúde de idosos hospitalizados e classificar o grau de complexidade assistencial. Métodos: Trata-se de estudo quantitativo, cuja amostra por conveniência foi constituída por 279 idosos. Utilizou-se o método Interdisciplinary Medicine Instrument (INTERMED), ferramenta que identifica aspectos biopsicossociais e condições do sistema de saúde e classifica a complexidade do paciente. Os dados foram submetidos à análise descritiva. Resultados: Predominou idosos do gênero feminino, aposentados, de cor branca, baixa escolaridade, casados e satisfeitos com as condições de saúde. A média de idade foi 72,3 anos. O domínio biológico foi o mais comprometido. Quanto à complexidade assistencial, 34,8 % dos pacientes requerem assistência multiprofissional. Conclusão: Os idosos apresentaram elevada complexidade assistencial, com maior comprometimento nos domínios biológico e sistema de saúde.

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“…40 Effective multidisciplinary teams improve patient outcomes in chronic disease management, such as reducing readmissions from heart failure, and improving blood pressure control in those with hypertension. 41,42 Since a physician needs more than 20 hours per day to provide recommended care to a panel of primary care patients, working with an interprofessional team is essential to patient care today. 43 Collaboration.…”

Section: Priority Area 1: Team-based Carementioning

confidence: 99%