目的:心臟衰竭出院後再住院率約14~50%,5年死亡率高達50%。若能建置屬於病人健康照護記錄,掌握病人居家狀況,給予即時反應,預知病患心衰竭惡化,降低病患再入院及死亡率。方法:本院於2013年成立「心臟衰竭照護小組」,強調跨領域團隊的全人照護及個案追蹤。2018年1月完成建置心臟衰竭健康管理 APP應用程式系統平臺,使用智慧型手機掌握病人居家狀況包括藥物、飲食、運動等日常生活注意事項。結論:本次專案與資訊室合作建置便利及創新服務之雲端管理模式,更重要的是機構提供的後端專業跨團隊醫療服務,營造心衰竭的健康管理系統醫療服務,並更進一步優化醫療團隊的支持系統,建置後端管理及緊急聯絡網,讓心衰竭個案回家後無後顧之憂,更省時、省力及省醫療費用。
Objective: Heart Failure is the 3- month rehospitalization rate was14-50%, the 5-year mortality rate is as high as 50%. If can create a personal health record. Predict the worsening of Heart failure, reduce patient readmission and mortality. Method: We Emphasizes the whole-person care and case tracking of cross-disciplinary teams. In January 2018 the establishment of a Heart Failure health management APP application system platform was completed. Use smart phones to grasp the patient's home conditions. Conclusion: Establish background management and emergency contact network. Let the Heart Failure patients have no worries after returning home, and save time, effort and medical expenses.