Transsektorale Versorgung von Patienten mit Herzinsuffizienz

Zusammenfassung

Unter transsektoraler Versorgung von Patienten mit Herzinsuffizienz versteht man das koordinierte optimale Zusammenwirken verschiedener Leistungserbringer im stationären und ambulanten Bereich. Hierdurch kann die Mortalität und Rehospitalisierungsrate signifikant reduziert werden bzw. die Leistungsfähigkeit und Lebensqualität nicht zuletzt durch eine Stärkung der Selbstverantwortung und -bestimmung dieser Patienten gesteigert werden. Voraussetzung ist allerdings ein supervidiertes, spezialisiertes Pflegepersonal, das die Vernetzung mehrerer Versorgungsebenen mit dem heimischen Umfeld des Patienten sicherstellt. Entscheidend für den Erfolg eines solchen multidisziplinären Managements ist weiterhin, das Disease-Management-Programm den individuellen regionalen Anforderungen, Bedürfnissen und nicht zuletzt limitierten finanziellen Ressourcen anzupassen.

Abstract

Transitional heart failure care is defined as the optimized joined effort of the in- and outpatient health care providers. It can decrease mortality und readmission rates significantly and furthermore increases the functional status and life quality of the patients, which is influenced as well by empowering patientʼs self-responsibility and determination. Specially trained supervised nursing staff is crucial for successfully linking the different health care sectors with the patientsʼ home environment. Furthermore it is essential for the success of such a multi-disciplinary management effort to adapt the Disease Management Programme to the individual regional requirements, needs and the limited financial resources.

Schlüsselwörter

transsektorale Versorgung - Herzinsuffizienz - Rehospitalisierung

Key words

Transitional Care Intervention - heart failure - rehospitalization

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