Turkiye Klinikleri Journal of Nursing Sciences

.: REVIEW
Kronik Hastalık Yönetim Modelleri: Geleneksel Derleme
Chronic Disease Management Models: Traditional Review
İlknur YAZICIOĞLUa, Gülcan BAĞÇİVANb
aMaltepe Üniversitesi Hemşirelik Yüksekokulu, İç Hastalıkları Hemşireliği ABD, İstanbul, Türkiye
bKoç Üniversitesi Hemşirelik Fakültesi, İç Hastalıkları Hemşireliği ABD, İstanbul, Türkiye
Turkiye Klinikleri J Nurs Sci. 2022;14(4):1251-7
doi: 10.5336/nurses.2022-91307
Article Language: TR
Full Text
ÖZET
 Kronik hastalıklar; 3 ay ya da daha uzun süren, genellikle yavaş ilerleme gösteren, birçok risk faktörünün neden olduğu periyodik izlem ve destek bakım gerektiren durumlardır. Dünya genelinde beklenen yaşam süresinin uzamasıyla birlikte, kronik hastalıkların görülme sıklığı giderek artmaktadır. Kronik hastalıkların giderek yaygınlaşması ile kronik hastalıkların kontrolü ve toplum temelli hastalık yönetimi programlarının önemi vurgulanmaktadır. Kronik hastalık yönetimi, özellikle bakımın koordinasyonu ve sürekliliğini sağlama, ekip çalışmasının desteklenmesi, bakım kalitesinin yükseltilmesi, beklenen hasta sonuçlarını iyileştirme ve bakım maliyetlerini azaltmada önemli ve etkin bir yöntemdir. Kronik hastalık yönetiminde modellerin kullanımı, kişiyi merkeze alarak bireye özgü bakımın kanıta dayalı bilgilerle multidisipliner olarak sunulmasını sağlamakla birlikte; hemşireler tarafından verilen bakımının sistematize edilmesini, birey ve ailesine holistik yaklaşılmasını ve yaşam kalitelerinin yükseltilmesini amaçlamaktadır. Modeller sayesinde hemşireler, bakım verdikleri bireye ilişkin birçok veriyi toplamakta ve analiz etmekte, elde ettikleri verileri kanıt temelli açıklayabilmekte ve buna bağlı hemşirelik bakımını gerçekleştirebilmektedirler. Kronik hastalık yönetimine ilişkin çok sayıda bakım modeli bulunmaktadır. Bu derlemede, hemşirelerin vazgeçilmez bir parçası olduğu kronik hastalık yönetiminde yaygın olarak kullanılan bakım modellerinden Kronik Bakım Modeli ve bileşenleri, Kronik Hastalıklar İçin İnovatif Bakım Çerçevesi, Kronik Hastalıkların Entegre Yönetimi Modeli, Kronik Hastalık Öz-Yönetim Programı ve Kronik Hastalık Yönetimi Bakım Modeli incelenmiş ve modellerin sağlık hizmeti sunumunda kullanılmasına yönelik öneriler sunulmuştur.

Anahtar Kelimeler: Kronik hastalık; bulaşıcı olmayan hastalıklar; uzun süreli bakım; hastalık yönetimi; organizasyonel modeller
ABSTRACT
 Chronic diseases are conditions that last 3 months or longer, usually progress slowly, require periodic follow-up and supportive care caused by many risk factors. With the prolongation of life expectancy around the world, the incidence of chronic diseases is increasing. The increasing prevalence of chronic diseases emphasize the importance of control of chronic diseases and community-based disease management programs. Chronic disease management is an important and effective method especially in ensuring the coordination and continuity of care, supporting teamwork, increasing the quality of care, improving expected patient outcomes and providing cost effectiveness. The use of models in chronic disease management ensures that individualized care is presented in a multidisciplinary manner with evidence-based information. In addition, it ensures the systematization of nursing care, a holistic approach to the individual and their families, and increasing their quality of life. By help of the models, nurses collect and analyze many data about the patient they care for, can explain the data they have obtained on the basis of evidence and perform nursing care accordingly. There are many models of care for chronic disease management. In this review, The Chronic Care Model and its components, Innovative Care for Chronic Diseases, Integrated Chronic Disease Management Model, Chronic Disease Self-Management Program and Chronic Disease Management Model of Care which are among the care models that nurses are an indispensable part of, are examined and also suggestions for using model in health service delivery are presented.

Keywords: Chronic disease; non-communicable diseases; long-term care; disease management; organizational models
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