A Chronic Disease Management Intervention for Home Care Patients with Cardio-Respiratory Symptoms: e DIVERT-CARE Intervention

The Canadian home care population is growing and cardio-respiratory chronic care needs are more prevalent. Specialized programs for self-management support are usually initiated during an acute episode or upon discharge om hospital. ese hospital and community-based outpatient programs are typically delivered by cardiac and respiratory disease management specialists and clinics, and only a small proportion of patients living with cardio-respiratory disorders have access to these. Self-management support provided in seings other than the home fail to account for challenges unique to the patient's home environment where self-management is practised. e DIVERT-CARE Intervention is a scalable, home-based, multi-component intervention to increase health literacy, optimize self-management behaviours, strengthen community supports, and increase co-management between home care and primary care providers. We describe the DIVERT-CARE Intervention components in detail, including the prerequisite nurse training and education, case-nding, and inter-professional self-management supports. is paper is relevant for the advancement of community nursing practice to adequately support the needs of home care patients with heart failure and COPD-related cardiorespiratory symptoms and promote clinical practice consistency across the healthcare system.

https://www.researchgate.net/publication/330600590_A_Chronic_Disease_Man...