Kronik hastalıkların yönetiminde, sağlık profesyonellerinin bakım modellerinden yararlanması önemlidir. Kronik Bakım Modeli kanıta dayalı sağlık sistemi değişikliklerinin sunulmasına imkân verebilmekte ve kronik hastalığı olan bireylerin birçok gereksinimini karşılayabilmektedir. Kronik Bakım Modeli'nin diabetes mellitus, kardiyovasküler hastalıklar, inme, kronik obstrüktif akciğer hastalığı ve kronik böbrek hastalığı gibi kronik hastalıkların yönetiminde kullanıldığı ve başarılı sonuçlar elde edildiği belirtilmektedir. Modelin bileşenleri kapsamında hemşirelerin bireysel/grup eğitimi, öz yönetim programları, danışmanlık, tarama, vaka yöneticiliği, hasta katılımlı taburculuk planlaması, ev ziyaretleri, telefonla izlem, kardiyak rehabilitasyon programı, poliklinik izlemi, ayakta tedavi programı, kanıta dayalı protokol kapsamında uygulanan geçiş bakımı gibi girişimler uyguladıkları görülmektedir. Kronik Bakım Modeline dayalı girişimler kronik hastalıkların yönetiminde etkili olabilmektedir. Modele ait iki veya daha fazla bileşenin uygulanması durumunda acil başvurularında ve tekrarlı yatışlarda azalma olabilmekte, öz etkililik ve öz yönetim becerisi artabilmektedir. Kronik Bakım Modeline temellendirilen girişimlerin etkisine yönelik çalışmaların yapılması, girişimlerin sağlık sistemine yerleştirilmesi ve sağlık profesyonelleri tarafından uygulanması, sonuçların sürekli olarak değerlendirilmesi ile kronik hastalık yönetiminin ve yaşam kalitesinin olumlu yönde iyileştirilebileceği düşünülmektedir. Bu derlemenin amacı, kronik hastalıkların yönetiminde Kronik Bakım Modeline temellendirilmiş girişimlerin etkinliğini incelemektir.
Anahtar Kelimeler: Modeller, hemşirelik; kronik hastalık
It is important for health professionals to benefit from care models in the management of chronic diseases.The Chronic Care Model can enable the presentation of evidence-based health system changes and meet many needs of individuals with chronic diseases.The Chronic Care Model is used in the management of chronic diseases such as diabetes mellitus, cardiovascular diseases, stroke, chronic obstructive pulmonary disease and chronic kidney disease and successful results are obtained.Within the scope of the model, the following interventions including individual/group training, self-management programs, counseling, screening, case management, patient participation discharge planning, home visits, telephone monitoring, cardiac rehabilitation program, outpatient clinic monitoring, outpatient treatment program and transition care initiatives are implemented by nurses under the evidence-based protocol. Interventions based on the Chronic Care Model can be effective in the management of chronic diseases. If two or more components of the model are applied, emergency applications and repeated hospitalizations may decrease, and self efficacy and self-management skills may increase.Chronic disease management and quality of life may be improved positively by health professionals through carrying out studies on the effect of interventions based on the Chronic Care Model, placing the interventions in the health system,implementing them by health professionals, evaluating the results continuously.The purpose of this review is to examine the effectiveness of interventions based on the Chronic Care Model in the management of chronic diseases.
Keywords: Models, nursing; chronic disease
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