心衰竭照護之跨領域整合性個案管理

The Multi-Disciplinary Integrated Case Management Program for Heart Failure

陳盈憲(Ying-Hsien Chen) ； 張嘉玲(Chia-Ling Chang) ； 李啟明(Chii-Ming Lee)

《台灣醫學》 26卷1期 (2022/01) Pp. 41-46

https://doi.org/10.6320/FJM.202201_26(1).0005

摘要

心衰竭（heart failure, HF）由於其高死亡率及高罹患率，成為近年來心血管領域的重要課題。雖然經過多年的努力、投注大量醫療資源，然而傳統的手術及藥物等治療成效，並不令人滿意。在本專輯當中，我們重新檢視心衰竭的病生理機轉，深入了解其複雜性，提出新的治療模式，以多專業醫療團隊進行整合性全面照護。邀請了心衰竭個案管理師、臨床藥師、心臟內外科醫師、物理治療師、臨床心理師及社工師，分別就心衰竭病人如何進行個案管理、心衰竭相關藥物使用、機械性循環輔助裝置適應症及照護常見問題、心肺復健、心衰竭病人社會及心理需求等議題，提出專業論述。藉由這種跨領域整合照護，補強過往由心臟科醫師獨挑大樑之不足，以期改善心衰竭的治療成效。

關鍵字

心衰竭 ； 跨領域整合性照護 ； 個案管理

並列摘要

Heart failure (HF) is the final common pathway of various cardiac diseases, characterized by its high mortality and morbidity. Despite the recent progress in pharmacotherapy and interventions, the outcome of HF is still unsatisfactory. In this issue, we review the complex pathophysiology of HF, evaluate the inadequacy of the classical physician-led, event-driven care system, and address a multi-disciplinary integrated care program coordinated by case managers specialized in HF. This program has been implemented as the heart failure post-acute care (HF-PAC) which is sponsored by the National Health Insurance Bureau in Taiwan. We invited reviews from cardiologists, cardiac surgeons, heart failure case managers, clinical pharmacists, physiotherapists, clinical psychologists, and social workers to discuss issues related to the integrated care of HF patients. Through the change from silo practice offered by cardiologist to multi-disciplinary integrated care, the outcome of HF patients is improved and the utilization of medical resources becomes more efficient.

並列關鍵字

heart failure ； multi-disciplinary integrated care ； case management

參考文獻

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