Recap - Innovative solutions for chronic diseases
Regional stakeholder meetings to investigate the process of the chronic care of heart failure from different angles
Health care of chronic diseases is getting increasingly complex, due to necessary involvement of various caregivers.These caregivers are situated in both in primary and secondary care groups., each with multiple stakeholders. Still, the relative role, the interaction between them and the processes included are hardly defined. These aspects may not only be relevant for patient care, but also for the setup of health care systems. Whereas the multidisciplinary team should resemble a seamless system across primary and hospital care, there is a scarcity of research considering how these disease management programs perform, in what form they should be offered, and what care and support patients and caregivers would benefit most.
As a consequence, information about patients is often incomplete, resulting in less effective treatment and safety problems.
We investigated the process of the chronic care of heart failure of the different actors in caregiving of these patient. Also processes of HF care, relevant players and interactions between them we investigated.
For the process of the care in the primary care intensively cooperation with Zio( “Zorg in ontwikkeling”, a regional GP organisation) resulted in the opportunity to interview some of the GP’s and their patients. Also data from medical charts of the interviewed HF patients was collected
The same was performed in the Maastricht University Medical Centre
It was found that the different caregivers address heart failure differently, communication is imperfect and importantly patient involvement is insufficient.
Telehealth solutions with patients being central, may help to overcome these current shortcomings.
Together with Sananet a telehealth device “Mijnhartfalencoach” was developed for patients with chronic heart failure. It is an internet application to support patients at home in a personalised way. Frequency of monitoring complaints and symptoms related to heart failure is variable, depending on the health status of the patient. Patients are also supported by learning modules to improve self-management skills and knowledge of heart failure.