Table 1 Implementation steps, objectives and methods of E-Coach chronic disease management model
Steps | Objectives | Implementation method |
|---|---|---|
1. Contact | Establish a good communication channel with patients, and regularly grasp the health status and needs of patients | Ask the patient to follow the WeChat official account of ‘Bai Qiu En Qian Yi Ren’ to regularly check the pushed video, fully discuss the evaluation results with the patients and their families, and formulate a health education plan in combination with the actual situation of the patients’ families; |
2. Observe | Understand the health needs of patients | Instruct patients to fill in the data of wjx.cn, and formulate the time and method of follow-up through the observation of the data trend line, including video, door-to-door, WeChat and outpatient review; |
3. Strengthen | Stress drug compliance, lifestyle, exercise and risk factors intervention to promote patients to implement health plans | (1) Urge patients to upload daily heart rate, blood pressure and blood sugar values (the frequency is determined according to the patient's evaluation results); (2) Fill in the amount of exercise on the day; (3) Exercise scheme: ① Buerger exercise. Ask the patient to lie on his back, raise his lower limbs by 45° for 1 ~ 2 min. In the sitting position, the feet droop naturally, and the combined actions of back extension, plantar flexion and circling are performed for 3 ~ 5 min; lay his lower limbs flat and rest for 2 ~ 5 min. Repeat the above actions continuously for 3 ~ 5 times, ② Fast walking training + Buerger exercise. Inform the patient to walk at the fastest speed on flat ground or a corridor with a length of 30 m to reach moderate to severe claudication level, then rest properly, resume walking after the pain disappears, and record the walking distance in this cycle. The training time is 30 min, and the training time is 3 times a week, step by step according to the patient’s tolerance. ③ Lower limb resistance training + fast walking training + Buerger exercise. Elastic belt training is used for lower limb resistance training, including five movements: hip walking lunge, knee lifting, standing side kicking, flexing feet back training and sitting leg kicking. Each movement is carried out in 2 ~ 3 times for 10 ~ 20 times, and the left and right legs are alternated, with a rest of 1 ~ 2 min between every two movements and training 3 ~ 5 times a week |
4. Clarify | Ensure the effectiveness and feasibility of the implementation of measures | According to the patient’s data detection trend chart, if it exceeds or exceeds the critical detection line, the specialist nurse will make adjustments according to the situation, such as guiding observation, suggesting medical treatment, WeChat/telephone/face-to-face, etc., and confirm the patient’s health status and problems; |
5. Help | Provide patient self-management support | Provide network resource help, and specialist nurses assess the patient's conditions and needs. If necessary, use the network to mobilize resources, refer and invite team doctors to start structured assessment; |
6. Encourage | Ensure the sustainability of patient cooperation | Give patients motivation intervention cycle, once every 3 ~ 4 weeks, combined with online and offline face-to-face interaction, to establish positive experience and give patients motivation; |
7. Educate | Provide education and support in knowledge and skills | Carry out media education in the form of education videos, graphic push, Q&As, interviews, etc., and conduct online consultation and education activities in combination with the needs of patients; |
8. Guide | Increase patients’ sense of accomplishment and integrate health goals into daily life | When the patient’s goal is achieved, the patient can share his experience with other patients and their families online to enhance his internal motivation |