Chronic disease management
Conditions
Interventions
Sponsors
Eligibility
Inclusion criteria
Inclusion criteria: 1. Patients with chronic diseases include chronic obstructive pulmonary emphysema, heart disease, and hypertension at home after discharge; 2. Aged >= 65 years; 3. Chronic disease hospital stay >= 1 week; 4. At least one professional assessment content is positive; 5. Communication skills are normal.
Exclusion criteria
Exclusion criteria: 1. Previous mental illness; 2. Multiple organ failure; 3. Advanced cancer; 4. Acute deterioration of the disease; 5. Unwilling to participate in this research; 6. Long-term residence in nursing homes; 7. Participation in self-management courses for specific diseases.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Readmission; | — |
Secondary
| Measure | Time frame |
|---|---|
| Economic indicators; | — |
Countries
China
Contacts
Shenzhen People's Hospital