Hospital management and transitional care of chronic disease
Code
11199
Academic unit
NOVA Medical School|Faculdade de Ciências Médicas
Department
MC
Credits
3
Teacher in charge
Profª Doutora Cândida Fonseca
Objectives
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Knowledge on an innovative hospital structure, dedicated to the proactive management of chronic diseases and decompensations in the hospital setting, and transitional care between hospital and primary health care. Experience the activity of a multidisciplinary team with care practice, teaching and research in full operation at Hospital São Francisco Xavier/Centro Hospitalar de Lisboa Ocidental Day Hospital.
- Learn the concept of Transitional Care between the hospital and outpatient setting.
- Practice effective communication methodology, mainly with Primary Care health practitioners
- Practice communication with patients, family members/caregivers about disease progression, adherence to non-pharmacological measures, pharmacological therapy (adherence, effects, adverse effects, dose titration)
- Teaching methodology about education on disease management and its monitoring
- Experience and understand the role of each health professional in a multidisciplinary team.
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Prerequisites
Subject matter
Experience and collaboration in care in outpatient setting, in the hospital, to chronic disease: Diabetes mellitus (DM), Heart Failure (HF), oral anticoagulation, anaemia of chronic diseases.
Education of patient and caregiver, on disease and self-control
Individualized therapeutic algorithm
Practice on Titration of drugs modifying disease (HF)
Treatment of acute complications, avoiding admission vs admission decision
Training in the management of IV drugs in day hospital avoiding admission
Timing for referral to a HF/DM consult vs primary care
Training on diagnosis of chronic disease anemia;
Familiarization with methodology of IV iron reposition and blood transfusion in outpatient setting
Indications of the anticoagulant drugs
Management of thromboembolic and hemorrhagic risk scores
Familiarization with the point-of-care methodology and computerized INR control program and coumarin dosage
Training interaction with primary health care
Contact with investigation teams: general methodology and duties of investigators, informed consent.
Bibliography
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Bibliography:
- International Diagnostic and Treatment Recommendations of Chronic Disease when available
- Action protocols of the MSDH
- Published texts by the faculty of OCU
- Bibliographical material obtained by internet search
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Teaching method
In the MSDH, students will work in direct interaction with the multidisciplinary team, namely nursing team, with the supervision of a doctor.
Activity Notebook
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Activity |
Executed |
Witnessed |
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Discussion of application of diagnostic protocol |
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Experienced therapeutic protocols |
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Punctures/Therapy:
IV (intravenous)
SC (subcutaneous)
IM (intramuscular) |
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Discussion of complementary diagnostic exams: ionogram, blood count, GFR calculation, liver function evaluation, natriuretic peptides
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Thoracic radiograph report |
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EKG report |
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Non-invasive monitoring |
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Blood transfusion/Flebotomy |
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IV Iron administration |
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Oxygen Therapy |
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Correction of hidroelectrolitic disturbances |
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Correction of fluid overload and treatment monitoring |
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Indications/Introduction of oral anticoagulants (OAC) |
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Monitoring of OAC patients |
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Training in transitional care |
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Education of patient/caregiver about disease and self-control |
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Clinical Investigation contact |
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Evaluation method
Assessment:
- Discussed report (Index 0,50) - (last day of the OCU)
- Continuous tutor´s evaluation (Index 0,50)
Report (Layout)
The student should compose a summarized report of the activities that should include the following:
- Tutor
- Summarized description of the location, the multidisciplinary team and his/her role in daily activities
- Registration of the executed activities and the witnessed activities
- Summarized description and critical evaluation of the developed activity and structure: MSDH.
Courses
