推動門診慢性腎臟疾病個案管理專案

An out Patient Based Case Management for Chronic Kidney Disease Patients

慢性腎臟疾病盛行，嚴重威脅健康及影響生活品質，更造成健保財務負擔，防治工作非常重要，也是國家醫療保健之重要方針。由於本院門診慢性腎臟疾病病人對疾病認知低，為提升服務品質及配合衛生署國民健康局保健防治政策，故引發動機。本專案目的在建立門診慢性腎臟疾病個案管理模式，依不同分期執行個別護理指導，以提昇慢性腎臟病病人對疾病之認知，防治疾病的惡化。專案結果：接受慢性腎臟病個廔管理人數共60名，佔醫師轉介人數之100%；病人接受護理指導後對疾病認知程度進步率達57.4%；病人對護理指導整體滿意度達83.4%。顯示本專案有效提升病人對疾病之認知，執行經驗可提供未來門診發展專科個廔管理之參考。

The increased prevalence of chronic kidney disease (CKD) in Taiwan has severely threatened people's well-beings. Fortunately, the prevalence of patients receiving maintenance dialysis therapy in Taiwan is among the highest rank in the world, and the tremendous expense for this care has heavily struck the healthcare system. Patients' indifference or ignorance is the major hindrance to obtaining timely medical support to prevent CKD deterioration. To consolidate the policy of the Bureau of Health Promotion and promote our healthcare quality, we have created the present program with the goal of improving patient cognition of CKD by intensive educational intervention. We designed the CKD structured education session by delivering individualized nursing instructions based on different stages of CKD. Sixty CKD patients, up to 100% of those referred from the nephrologists in our institution, were consecutively enrolled. After specific one-on-one nursing instructions, the participants have significantly improved their knowledge (57.4%) of the disease entity. Patient evaluations of the nursing education reached an 83.4% satisfaction rate. The present investigation highlights the pivotal roles of nurse practitioners and timely nursing education in improving patient cognition of the disease. Our successful experience in CKD might help to formulate outpatient based case management programs in other subspecialties.