Team approaches and issues of a substantial cooperation across professions via the “Ohisama-Network” system

Abstract

Due to the medical procedure for terminal patients who were suffering from chronic heart failure which commonly include administration of diuretics and cardiac stimulants via continuous intravenous injection such as catecholamine, the patients are often forced to extend their stay in hospital, resulting in low quality of life (QOL). However, if the circulatory system was maintained stable with appropriate drug administration, it is certain that some percentage of patients were able to stay in their self-reliant recuperation environment. Thus, the possibility of realization of medical management for home care patients by respecting their own intentions cannot be denied. In such a patient group who prefers to receive at-home care treatment with an appropriate recuperation environment, support from their family and a close coordination among homecare facilities, physicians, as well as logistic medical service must be required. We have constructed and utilized such network-system called “Ohisama-Network”, consisting of both specialized medical personnel for home care and staff with no specialized qualifications, to practice a smooth cooperation across professions around our clinics to support patients. We report a significant case study how Ohisama-Network contributed to improve QOL of home care patients with a terminal state of chronic heart failure, who were unable to disengage from catecholamine. Furthermore, we report some practical approaches of home healthcare via Ohisama-Network. In order to introduce patients with serious conditions into home care and improve their QOL, unconventional framework and substantial cooperative relations across professions must be urgently developed.