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個案管理對慢性病患者之長期成效評估

研究計畫名稱:個案管理對慢性病患者之長期成效評估

年度:102-105

計畫主持人:江欣虹、蕭伊祐、黃蕙茹、蔡淑蘭、邱善筠、林妙秋

執行期間:102/07/01-106/07/31

研究結果對全人照護品質及病人安全改善具體事證:
                 目前本院健康管理中心之個案管理共有16科疾病別包括類風濕性關節炎,糖尿病,肺結核,心衰竭,慢性腎臟病,腦中風等疾病,依疾病不同需求,運用個案管理的照護模式,給予提供最適切的照護計畫及評值。過程中,除了本身疾病的病情外,更關注到飲食衛教,憂慮情緒,社會失能,戒煙,性功能障礙等面向,系統能提醒各科個案管理師多重疾病重覆多人管理的發生,可達整合性的照護管理。結果面,更能落實每位管理個案的照護追蹤,以提升個案對自我的照顧能力,延緩及避免併發症的發生,進而減少住院及醫療成本。
       在研究方面102-105年,共依據個案管理照護提出院內研究計畫案共9件,已結案7件,目前尚有2進計畫案持續進行中。102-105年共發表62篇(不含投稿中),其中SCI 8篇、國內雜誌發表4篇;國內外學會Oral 4篇、Poster46篇。

論文發表: 

1.  Chiang HH, Livneh H, Yen ML, Li TC, Tsai TY. Prevalence and correlates of depression among chronic kidney disease patients in Taiwan. BMC Nephrol. 2013 Apr 4;14:78.(SCI,1.52,62.3%)
2.  Chiu SY, Livneh H, Tsao LL, Tsai TY1. Acceptance of disability and its predictors among stroke patients in Taiwan. BMC Neurol. 2013 Nov 14;13:175.(SCI,1.52,62.3%)
3.  Lin MC, Guo HR, Lu MC, Livneh H, Lai NS, Tsai TY. Increased risk of depression in patients with rheumatoid arthritis: a seven-year population-based cohort study. Clinics (Sao Paulo). 2015 Feb;70(2):91-6. (SCI,5.59,12.9%)
4.  Chiang HH, Guo HR, Livneh H, Lu MC, Yen ML, Tsai TY. Increased risk of progression to dialysis or death in CKD patients with depressive symptoms: A prospective 3-year follow-up cohort study. J Psychosom Res. 2015 Sep;79(3):228-32.(SCI,2.84,37.3%)
5.  Chiang HH, Livneh H, Guo HR, Yen ML, Tsai TY. Effects of acceptance of disability on death or dialysis in chronic kidney disease patients: a 3-year prospective cohort study. BMC Nephrol. 2015 Dec 5;16:202. (SCI,2.28,37.6%)
6.  Lu MC, Guo HR, Lin MC, Livneh H, Lai NS, Tsai TY. Bidirectional associations between rheumatoid arthritis and depression: a nationwide longitudinal study. Sci Rep. 2016 Feb 9;6:20647. (SCI,5.22,11.1%)
7.  Tsai SL, Lai CL, Chi MC, Chen MY. Changes in cigarette smoking and health promoting behaviors in different treatment stages among non-HIV tuberculosis patients in rural areas. J Clin Nurs. 2016 Sep;25(17-18):2511-9. (SCI,1.38,29.3%)
8.  Chiang HH, Hong RM, Tsai JP, Chen MY. The Lived Experiences of Living with LPD among CKD Patients in Southern Taiwan. Neuropsychiatry   Journal. 2016; 6:6 (SCI, 1.45,70.4%)
9.  Hsiao IY, Chien CY, Chen CW, Lin TK, Koo M. Predictors of lack of improvement in left ventricular ejection fraction among atients with congestive heart failure 18 months after the commencement of a disease management program: a prospective observational study. Tzu Chi Medical Journal (2015) 27,164-169.
10. 江欣虹, 賴寧生, Hanoch Livneh, 葉美玲, 蔡宗益 中文版簡式疾病接受度量表之信效度 志為護理2013,12(1),66-76.
11. 林妙秋、呂明錡、蔡宗益 台灣類風濕性關節炎患者憂鬱症之世代追蹤研究 志為護理2013,12(6),66-74.
12. 黃蕙茹, 蔡宗益 女性糖尿病患者之性功能障礙.志為護理2016,15(3),70-80. 
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