The Role of Nursing in Disease Management. Weber P. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. Disease Management
Nursing

2. What’s disease management
Effectiveness
Preventive and curative interventions
Efficiency
Increase the quality of care
Reduce the global cost
Promoting patient or family self management

3. Health care environement
• GPs care for and encourage patient
to join disease management
program.
• Nurses, physical therapist,
nutritionist, physical trainer, social
worker and other care takers
• Patient and family have the key role

4. Success of disease
management
• Reducing costs by
• Prevention of complications
• Reducing hospitalization or re-hospitalization
• Reducing MD specialist encounters
• Participation in HMOs or managed care
• Increasing the effectiveness, efficiency
• Following best practice
• Education and training

5. Hospitals are also concerned
• Not only when the patient is discharge
• During hospital stays:
• Critical pathways
• Evidence based
• Nurses are best positioned to manage the
stay and prepare the discharge.
• Coordinate care after discharge from multi-
discipline team

6. Nurses’ roles
• Caring and prevention
• Coordination across the health
care provider team
• Do patient and family education
• Conduct research
• Contribute to evidence based

7. Nurses’ roles
• In Gonseth et al. study, nurses play a key
role in the follow up for patient with heart
failure or cardiovascular causes
• In the 27 studies screened 18 reported that
nurses played a central role in the disease
management
• 30% reduction of re-hospitalization over 3160
patients

8. Training
• For patient education, nurses need
competencies in:
• Evidence based
• Clinical research
• Prevention
• Psychosocial aspects
• PHR structure and goals
• EHR structure and goals

9. Role of IT
• Personal health record allows the
patient to:
• Self monitor
• Communicate
• Record
• Empower decision

10. Thank you
Questions

11. References
• Gaspoz JM. Rutschmann O Faut-il avoir peur du disease management 1 Volet hopistalier
Revue médicale Suisse. Revue-medhyg.ch revue.medhyg.ch/article.php3?sid=30798
accessed 30.01.2010
• Goldstein P. Impact on disease management programs on hospital and community
nursing Practice. CNE series. Nursing Economics (Nov-Dec) 2006 vol. 24 no 6 pp 308-
313
• Gonseth J. Guallar-Castillon P, Banegas J.R, Rodrıguez-Artalejo F, The effectiveness of
disease management programmes in reducing hospital re-admission in older patients
with heart failure: a systematic review and meta-analysis of published reports. Elsevier
Ltd European Heart Journal (2004) 25, 1570–1595
• Fletley Brennan P. Promotion Health through better Personal Health Information
Management. HIMSS Atlanta March 2010
• Rutschmann O. Gaspoz JM. Faut-il avoir peur du disease management 2 Volet
ambulatoire Revue médicale Suisse. Revue-medhyg.ch
revue.medhyg.ch/article.php3?sid=30799 accessed 30.01.2010
• Vinne van der E. The ultimate goal of disease management: improved quality of life by
patient centric care. International Journal of Integrated Care – Vol. 9, 10 August 2009 –
ISSN 1568-4156 – http://www.ijic.org/ accessed 30.01.2010