Health systems are being transformed to provide patients with integrated care, and in this context empowerment of the patient and/or caregiver becomes a key health-related process. Thus, empowerment allows patients to take an active role in managing their disease by acquiring greater control over the decisions and actions that affect their health.
Within the framework of the European Carewell, project, the aim of which is to improve the care of chronic patients by enhancing coordination between healthcare professionals and following-up and empowering patients, a group mainly comprising nursing staff has developed a structures programme for the empowerment of complex chronic patients (multiple co-morbidities), known as the Kronik ON programme©. The aim of this programme is to allow patients to understand their diseases, helping them to detect and control their warning signs and symptoms, thus allowing them to develop the capacity to self-manage their diseases. An additional aim of the programme is to educate patients in how to adopt the healthy lifestyles recommended for their diseases. The programme also contemplates training activities for the caregivers of these patients to increase their ability to manage the diseases concerned as many of these patients are unable to look after themselves and depend to a large extent on informal caregivers.
The Kronik ON Programme© comprises four training sessions covering topics such as evaluation of the patient, explanation of the diseases identified, treatment adherence, healthy lifestyles and self-control of warning signs and symptoms.
During the empowerment sessions, the reference nurses will use materials regarding the most prevalent diseases in these patients, such as educational materials on heart failure, diabetes or COPD. In addition, patients will be provided with information sheets concerning their diseases. They will also be provided with a self-care diary in which the objectives agreed with the patient as regards the adoption of a healthy lifestyle will be set out and in which the values to be controlled will be recorded.
All this material, together with videos summarising the relevant aspects of the most prevalent diseases in these patients, can be found in the Osasun Eskola section of the Osakidetza web site, www.osakidetza.euskadi.eus/kronikonprograma , está disponible todo el material, además de vídeos que resumen los aspectos relevantes sobre las patologías más prevalentes en estos pacientes.
El Departamento de Salud del País Vasco lleva trabajando en la mejora de la atención a pacientes crónicos complejos desde hace años y como área prioritaria desde el año 2011. Carewell representa un avance en la mejora continua de la atención a estos pacientes, al tratarse de un nuevo método cuyo objetivo es fomentar la creación de una experiencia profesional más rica y resolutiva, donde el profesional sienta que en el proceso de empoderamiento de los pacientes tiene un papel importante para que éstos puedan interiorizar nuevos conceptos y hábitos, y conseguir promover la utilización de las tecnologías en los cuidados integrales.
Convocatoria del proyecto: CIP-ICT Policy Support Programme 2013-7
Nº de proyecto: 620983