Description
Disease management programmes have been developed to counteract the further increase of chronic diseases, prevent or postpone complications and comorbidity for as long as possible and promote quality of life and control of one’s own health. In the Noord-Kennemerland region, the Care Group has established a care programme to provide structured COPD care in the region. The regional care currently provided to COPD patients varies greatly. An implementation plan has therefore been developed to optimise COPD care. The plan will be phased in on a modular basis to arrive at uniform provision of care to COPD patients. The diversity of practices will be taken into account. The modules encompass both training and support. Specific entry requirements and results are described for each module.
Project leader and secretary:
Assessment study
The study will focus on patients included in Kennemer Lucht’s COPD care programme, looking at the patient’s care experience and quality of life. A number of clinical values will also be studied. The COPD patients will be systematically monitored over the course of three years. During this period, patients and their care professionals (general practitioners, practice support nurses or assistants) will be given a questionnaire to complete at three different times (September 2011, 2012 and 2013). An extract from the General Practitioners’ Information System (HIS) will be used to draw up an inventory of several clinical data about the included COPD patient.
Research
Sponsor
- Boehringer Ingelheim
Partners
- Noord-Kennemerland General Practitioner Care (HZNK)
Publicaties
1. Cramm, J.M., Nieboer, A.P., The Relationship between Self-Management Abilities, Quality of Chronic Care Delivery and Well-Being among Patients with Chronic Obstructive Pulmonary Disease in the Netherlands, International Journal of COPD