慢性心力衰竭病人疾病管理研究进展

Research progress on disease management in patients with chronic heart failure

从疾病管理干预措施、疾病管理模式两个方面对慢性心力衰竭病人的疾病管理进行了介绍,具体从心力衰竭治疗小组的成立、心力衰竭门诊的建立、电话随访系统的应用、家庭访视、家庭远程监护、病人的自我护理行为、以家庭为中心的干预、以社区为单位的管理、医院-社区联合的病人系统管理等方面进行了综述。

It introduced the disease management of patients with chronic heart failure from the aspects of disease management interventions and disease management models,especially from the establishment of the treatment group of heart failure,the establishment of heart failure clinics,the application of telephone follow-up system,family visit,family Remote care,patient self-care behavior,family-centered intervention,community-based management,hospital-community patient system management,and so on.