Cementing Pathways Home: Enhancing Quality of Life for People with Chronic Obstructive Pulmonary Disease

Abstract

While in past years there have been multiple attempts to address the issues surrounding the community/acute care interface, current outcomes suggest that few in Tasmania have achieved their goals for older people with chronic diseases, who continue to be high users of acute facilities. This presentation details the Pathways Home Chronic Respiratory Partnerships Project - a controlled study of a transferable, community-based program of self-management, supported by phone mentoring and patient symptom monitoring, compared with usual care. A multidisciplinary collaboration between the University of Tasmania's Schools of Medicine, Nursing, and Information Systems, the project focuses on those with respiratory conditions due to their high level of hospital presentations. The evaluative process ensures transferability to other chronic conditions. Aims: 兮hanced self-efficacy and quality of life for patients with chronic obstructive pulmonary disease (COPD) through interactions with mentors and use of a technology-supported system of self-management 剮creased capacity for community health nurses (CHN's) to manage people with chronic disease by a shift in practice from a problem/task focus to facilitation of patient self management Method: Patients are: 咥cruited while an inpatient 吲ovided with a CHN mentor following discharge 偳ked to monitor and record daily symptoms in a paper diary, graduating to technological formats as able 僯mpared with usual care