Investigation of the integrated care model based on patients′demand in in-charge patients with chronic kidney disease
10.3760/j.issn.1674-2907.2015.06.017
- VernacularTitle:基于患者需求的院内慢性肾脏病一体化护理转诊模式探讨
- Author:
Ying XU
1
;
Liyun CAO
;
Junye TIAN
;
Chongyan YU
;
Liping LI
;
Yanmeng GUAN
Author Information
1. 100034 北京大学第一医院肾内科 北京大学肾脏病研究所卫生部重点实验室 教育部慢性肾脏病防治重点实验室
- Keywords:
Chronic kidney disease;
Integrated care;
Referral pattern
- From:
Chinese Journal of Modern Nursing
2015;21(6):663-665
- CountryChina
- Language:Chinese
-
Abstract:
Objective To investigate effect of the integrated care model based on patients′demand in in-charge patients with chronic kidney disease ( CKD) .Methods Established CKD integrated care team , and a questionnaire survey about knowledge and disease management was conducted in hospitalized CKD patients from January to May, 2013, and established the CKD care referral model in hospital .Results A total of 150 cases of hospitalized patients with CKD received a questionnaire .The scores of patients′awareness of CKD was (4.41 ± 1.11), and the knowledge about kidney disease was (3.21 ±0.84), and the degree of concern for knowledge of disease was (2.75 ±1.30), and disease self-care technology mastery was (1.39 ±0.83).88.67% and 60.00%patients considered disease knowledge received from healthcare professionals , but there were still a large number of patients received knowledge from the media , friends, etc.105 patients (70.00%) hoped to get nursing care of outpatient follow up and education .The integrated care referral pattern in hospital was initially established after team discussion which could provide targeted patients pre-referral care and education , coordinated with one by one referral patterns with one transfer form , post-referral care and education .There were 81 nurses joined the post-referral care and gave their suggestions .Conclusions CKD patients need long-term, continuous, complete and individualized health care and education .Establishment of integrated CKD care referral patterns may be an appropriate way to solve this issue .
