Transitional Care Model With Self-management Ability As The Core Applied Research In Patients With COPD

Objective:To explore the application effect of the transitional care model with self-management ability as the core in COPD patients,in order to provide empirical evidence for clinical transitional care intervention for COPD patients.Methods:Using convenient sampling method,60 patients with moderate to severe COPD who were hospitalized for acute exacerbation of COPD in a three-level general hospital of Zunyi City from January 2018 to June 2018 were randomly divided into control group(30cases)and intervention group(30 cases).The control group was given routine care in respiratory medicine,that is,the responsible nurses gave health education and discharge guidance during the hospitalization of the patients;the intervention group was given the transitional care model intervention with self-management ability as the core,that is,health guidance during hospitalization and follow-up intervention after discharge from the respiratory nurse and researcher.COPD self-management scale,COPD self-efficacy scale,modified British Medical Research Council dyspnea scale,6-minute walk test,St.George's respiratory questionnaire and COPD transitional care patient satisfaction questionnaire were used to evaluate the patients' self-management ability,self-efficacy level,dyspnea symptoms,exercise endurance,quality of life and satisfaction.Through patient/main caregivers of families reports and hospital HIS system,the emergency treatment and readmission of patients due to acute exacerbation of COPD after discharge were obtained.The self-management ability,self-efficacy level,dyspnea symptoms,exercise endurance and quality of life of the two groups of patients at the time of admission,3 and 6 months of intervention,emergency treatment and readmission for 3 and 6 months of intervention,and satisfaction for 6 months of intervention were analyzed and compared.Results:1.Self-management ability: There was no significant difference in self-management ability score between the two groups(P>0.05).After intervention for 3 months,the self-management ability score of the intervention group(165.77�15.48)was higher thanthat of the control group(136.93 � 9.79),the difference was statistically significant(P<0.05);after 6 months of intervention,the self-management ability score of the intervention group(166.10 � 15.00)was higher than that of the control group(132.80�7.91),and the difference was statistically significant(P<0.05).2.Self-efficacy level: There was no significant difference in self-efficacy scores between the two groups(P>0.05).After 3 months of intervention,the self-efficacy scores of the intervention group(75.38�11.39)were higher than the control group(69.97�6.91),the difference was statistically significant(P<0.05);after 6 months of intervention,the self-efficacy score of the intervention group(74.49 � 11.27)was higher than that of thecontrol group(69.93�6.26),and the difference was statistically significant(P<0.05).3.Symptoms of dyspnea: At the time of enrollment,there was no significant difference in the scores of dyspnea symptoms between the two groups(P>0.05).In the intervention group,the dyspnea symptom score(1.77�0.43)was lower in the interventiongroup than in the control group(1.85 � 0.46),the difference was statistically significant(P<0.05);after 6 months of intervention,the dyspnea symptom score(1.60�0.50)in theintervention group was lower than that in the control group(1.78�0.58),and the differencewas statistically significant(P<0.05).4.Exercise endurance: There was no significant difference in the distance between the two groups in the 6-minute walking test(P>0.05).In the intervention group,the6-minute walking distance(392.41�28.18)in the intervention group was higher than thatin the control group.(353.82�38.32),the difference was statistically significant(P<0.05);after 6 months of intervention,the distance of the 6-minute walk test(388.32�32.71)in theintervention group was higher than that in the control group(351.25 � 35.94),and thedifference was statistically significant(P<0.05).5.Quality of life: There was no significant difference in the total scores of St.George's Respiratory Questionnaire between the two groups(P>0.05).After 3 months of intervention,the total score of St.George's Respiratory Questionnaire(58.95�17.53)in theintervention group was lower than that of the control group(65.05�18.26),the differencewas statistically significant(P<0.05);after 6 months of intervention,the total score of the St.George's Respiratory Questionnaire(55.04�17.68)in the intervention group was lowerthan that in the control group(63.29�18.34),and the difference was statistically significant(P<0.05).6.Emergency treatment and readmission: After 3 months of intervention,the number of emergency treatment,hospitalization times,hospitalization days and hospitalization expenses of patients in the intervention group were lower than those in the control group,with statistically significant difference(P<0.05),but there was no statistically significant difference between the two groups at 6 months(P>0.05).7.Satisfaction: At the 6 months of intervention,the overall satisfaction score(60.73 � 2.02)of the intervention group was higher than that of the control group(40.97�6.64),and the difference was statistically significant(P<0.05).Conclusion:1.The transitional care model can improve the self-management ability and self-efficacy of patients with COPD,improve the symptoms of dyspnea,improve exercise endurance and quality of life,.and reduce the emergency treatment and readmission caused by acute exacerbation of COPD within 3 months after discharge.2.The transitional care model has been recognized by patients,and patient satisfaction is high,which is worthy of promotion in the transitional care of COPD chronic disease management.