發展與建構心臟衰竭病人之協同健康照護方案

Develop and Construct a Collaborative Health Care Program for Patients with Heart Failure

心臟衰竭是全球面臨的重大健康挑戰，對醫療系統造成嚴重影響。隨著罹病率增加，多學科團隊整合性介入策略已顯示改善治療效果的成效。本文以系統性文獻回顧方式發展與建構心臟衰竭協同健康照護方案。採二階段步驟進行，第一階段以PICO設定關鍵字及Mesh詞彙於5個資料庫搜尋2014至2024年的文獻，共獲得12篇隨機對照試驗研究，以Jadad量表評估研究品質，並於每篇研究中提取心臟衰竭照護的關鍵措施。第二階段發展及建構心臟衰竭協同健康照護方案，強調多學科團隊合作，包含護理指導手冊及影片、每週團隊會議、門診和電話追蹤等措施，介入總時間為3個月，每週至少進行一次介入，期能為臨床照護提供實證依據並參考，協助病人獲得症狀控制及功能恢復，提升生活品質。

Heart failure is a major global health challenge that significantly impacts healthcare systems. As the prevalence of heart failure increases, multidisciplinary team-based integrated intervention strategies have shown improved treatment outcomes. This study develops and constructs a collaborative health management program for heart failure through a systematic review. The research was conducted in two phases. In the first phase, keywords and MeSH terms were set using the PICO framework to search five databases for literature from 2014 to 2024. A total of 12 randomized controlled trials were identified, and quality was assessed using the Jadad scale. Key measures of heart failure care were extracted from each study. In the second phase, a collaborative health management program for heart failure was developed and constructed, emphasizing multidisciplinary team collaboration. This includes nursing guidance manuals and videos, weekly team meetings, outpatient and telephone follow-ups, among other measures. The total intervention duration was designed to be three months, with at least one intervention per week. The program hoped to provide evidence-based reference for clinical care providers, helping patients achieve symptom control and functional recovery, thereby improving their quality of life.