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Wiener klinische Wochenschrift

, Volume 126, Issue 21–22, pp 734–741 | Cite as

HerzMobil Tirol network: rationale for and design of a collaborative heart failure disease management program in Austria

  • Andreas Von der Heidt
  • Elske Ammenwerth
  • Karl Bauer
  • Bettina Fetz
  • Thomas Fluckinger
  • Andrea Gassner
  • Willhelm Grander
  • Walter Gritsch
  • Immaculata Haffner
  • Gudrun Henle-Talirz
  • Stefan Hoschek
  • Stephan Huter
  • Peter Kastner
  • Susanne Krestan
  • Peter Kufner
  • Robert Modre-Osprian
  • Josef Noebl
  • Momen Radi
  • Clemens Raffeiner
  • Stefan Welte
  • Andreas Wiseman
  • Gerhard Poelzl
original article

Summary

Heart failure (HF) is approaching epidemic proportions worldwide and is the leading cause of hospitalization in the elderly population. High rates of readmission contribute substantially to excessive health care costs and highlight the fragmented nature of care available to HF patients. Disease management programs (DMPs) have been implemented to improve health outcomes, patient satisfaction, and quality of life, and to reduce health care costs. Telemonitoring systems appear to be effective in the vulnerable phase after discharge from hospital to prevent early readmissions. DMPs that emphasize comprehensive patient education and guideline-adjusted therapy have shown great promise to result in beneficial long-term effects. It can be speculated that combining core elements of the aforementioned programs may substantially improve long-term cost-effectiveness of patient management.

We introduce a collaborative post-discharge HF disease management program (HerzMobil Tirol network) that incorporates physician-controlled telemonitoring and nurse-led care in a multidisciplinary network approach.

Keywords

Telemonitoring Disease management program Chronic heart failure HerzMobil Tirol network 

HerzMobil Tirol Netzwerk: Rationale und Design eines sektorenübergreifenden Betreuungsnetzwerks mit Telemonitoring für Patienten mit Herzinsuffizienz in Österreich

Zusammenfassung

Herzinsuffizienz ist der häufigste Grund für Krankenhausaufnahmen bei älteren Patienten. Die hohe Anzahl rascher Wiederaufnahmen nach Entlassung sind mit hohen Kosten verbunden und widerspiegeln die bislang unzureichende Versorgung dieser Patienten. Disease-Management-Programme (DMPs) sollen die Schnittstellenproblematik zwischen Krankenhaus und niedergelassenem Bereich sowie Lebensqualität und klinischem Langzeitverlauf verbessern, die Eigenkompetenz von Patienten stärken und langfristig die Kosteneffektivität der Versorgung erhöhen. Mit Hilfe von telemedizinischen Einrichtungen können die häufigen Wiederaufnahmen in der vulnerablen Phase nach Krankenhausentlassung reduziert werden. Eine langfristige Stabilisierung ist allerdings nur mit DMPs möglich, welche eine umfassende Schulung von betroffenen Patienten sowie eine konsequente Therapieoptimierung zum Ziel haben. Es ist wahrscheinlich, dass die Kombination derartiger DMPs mit telemedizinischen Systemen sowohl die Effizienz als auch die Kosten-Effektivität der Patientenversorgung verbessert.

Wir berichten über ein integratives Versorgungsprojekt für Patienten nach akuter kardialer Dekompensation, bei dem ein nicht-invasives Telemonitoringsystem in ein umfassendes, sektorenübergreifendes Betreuungsnetzwerk eingebunden ist.

Schlüsselwörter

Telemonitoring Disease Management Programm Chronische Herzinsuffizienz HerzMobil Tirol Netzwerk 

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Copyright information

© Springer-Verlag Wien 2014

Authors and Affiliations

  • Andreas Von der Heidt
    • 1
  • Elske Ammenwerth
    • 2
  • Karl Bauer
    • 3
  • Bettina Fetz
    • 1
  • Thomas Fluckinger
    • 4
  • Andrea Gassner
    • 5
  • Willhelm Grander
    • 6
  • Walter Gritsch
    • 7
  • Immaculata Haffner
    • 8
  • Gudrun Henle-Talirz
    • 3
  • Stefan Hoschek
    • 9
  • Stephan Huter
    • 7
  • Peter Kastner
    • 10
  • Susanne Krestan
    • 6
  • Peter Kufner
    • 11
  • Robert Modre-Osprian
    • 10
  • Josef Noebl
    • 7
  • Momen Radi
    • 7
  • Clemens Raffeiner
    • 5
  • Stefan Welte
    • 10
  • Andreas Wiseman
    • 12
  • Gerhard Poelzl
    • 1
  1. 1.Clinical Division of Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
  2. 2.Department of Biomedical InformaticsUMIT—University for Health Sciences, Medical Informatics and TechnologyHall in TirolAustria
  3. 3.Department of Internal MedicineNatters State HospitalNattersAustria
  4. 4.Private PracticeWattensAustria
  5. 5.Department of Internal MedicineHochzirl State HospitalZirlAustria
  6. 6.Department of Internal MedicineHall/Tirol State HospitalHall in TirolAustria
  7. 7.Private PracticeInnsbruckAustria
  8. 8.Private PracticeHall in TirolAustria
  9. 9.Private PracticeZirlAustria
  10. 10.Safety and Security DepartmentAIT Austrian Institute of Technology GmbHViennaAustria
  11. 11.InnsbruckAustria
  12. 12.Private PracticeSeefeldAustria

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