The Application Of Transitional Care Based On “Heart Care Network” In Patient With Coronary Heart Disease

Objectives The study intervened patients that participated in “heart care network” in transitional care model, to observe the effects on perceived knowledge scale for CHD, abilities for health practice, the quality of life, clinical outcomes a nd readmission rate in patients with coronary heart disease(CHD), and to explore suitable discharged method and basis for CHD patients under current hospital system.Methods The study included 127 CHD patients who met the inclusion exclusion criteria and willing to participate in.They were selected from cardiovascular wards of Thangshan Gong ren hospital from early November 2013 to the end of February 2014. They were randomly divided into control-group(CG, n=63) and intervention- group(IG, n=64). Both of the groups were established electronic archives after admission, received management and health education under the “heart care network” by nurses of the ward. The controlgroup regularly participated in lectures and received follow- up after discharge by outpatient department. The intervention-group received further transitional care. There were two parts of the intervention given to the subjects in the intervention-group. The subjects received the assessment of information and individual guidance, were gived reading materials and diary based on their readiness of change when they were hospitalized and received the transitional care model intervention after they discharged. The study compared the change of perceived knowledge scale for CHD, self-rated abilities for health practice, the quality of life, the clinical outcomes and readmission rate between two groups before and after 6 months intervention. SPSS 13.0 was used to analyse date.Results 1 A total of 127 subjects were recruited into this study, 8 subjects dropped out of this study. Results were presented on the remaining 119 subjects with 58 in the controlgroup and 61 in the intervention- group. There weren’t statistical differences in the baseline of the clinical date between the two groups before intervention(P>0.05). 2 The score of perceived knowledge scale for CHD: after the intervention, the control- group was(62.22±12.88) points; the intervention- group was(78.67±12.60) points, the difference was statistically significant(P<0.05). There were significantly changes in all dimensions except inspect item(P<0.05). 3 The score of self-rated abilities for health practice: after the intervention, the score of self-rated abilities for health practice was higher in the intervention- group than in the contro l- group, there were significantly changes in the total score and all the dimensions(P<0.05). 4 The score of quality of life: after the intervention, the quality of life was higher in the intervention-group than in the control- group, there were significantly changes in the final score and angina stability, angina frequency, disease perception and treatment satisfaction dimensions(P<0.05). 5 The compare of clinical outcomes: after the intervention, the systolic blood pressure(SBP), the body mass model(BMI), the total cholesterol(TC), the triglycerides(TG) and the low density lipoprotein(LDL) were lower in the intervention-group than in the control- group(P<0.05).Conclusions 1 The transitional care model based on “heart care network” with the patients of coronary heart disease can effectively improve the perceived knowledge scale for CHD and the abilities of health practice. 2 The transitional care model based on “heart care network” with the patients of coronary heart disease can improve the quality of life and the clinical outcomes.