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Results of 12 month follow up in Tulppa outpatient rehabilitation program What is -program? • a group rehabilitation program for patients with cardiovascular disease, type 2 diabetes or mild cerebrovascular disorders. • the program is also meant for those who have risk factors for vascular diseases. • the groups meet mostly in the public health care centres • Finnish Heart Association developed the program in 1999 – 2002 (pilot project) Why -program is needed? • the hospital stays have reduced because of the improved and more effective treatment interventions not enough time for the patient counselling • not enough resources for counselling in health care centres • discharge from hospital is the critical phase in treatment • problems in psychosocial recovery: for example depression is common but is recognized poorly • Follow up after hospitalization and secondary prevention are not carried out the way they should be patients’ risk factors need improvement (EUROASPIRE I, II and III) Where –program is currently running • 8 hospital districts (7 Heart Districts) Etelä-Karjala, Etelä- and Itä-Savo, Kymenlaakso, Pohjois-Karjala, PohjoisSavo, Pirkanmaa and Päijät-Häme Aims at community level • to expand and systematize rehabilitation in the primary health care as a part of the integrated pathway • to find the optimal way for each area to produce rehabilitation services: cooperation between health care centres, heart districts and private sector • to get 1000 – 1200 new patients yearly into the rehabilitation groups • to reduce artery disease patients’ need for health care services and that way to reduce the costs Aims at individual level • to get the rehabilitation programs as close as possible to the patient’s surroundings • to reduce risk factors by lifestyle counselling and slow down the progression of the disease • to promote recovery, functional status and ability to work • to support psychosocial recovery and discover early enough the possible depression • to provide peer support • to improve the quality of life Operational model of the program • There are about ten patients in a rehabilitation group. • They gather together in the health care centre once a week for ten weeks (2,5 – 3 h/session). • After that there are two follow up meetings 6 months and 12 months from the beginning of the program. • It is a nurse-led program and most of the groups also have a peer member, who is an experienced cardiac patient. • Follow up 0, 6 ja 12 months (lipids, glucose stress test, blood pressure, BMI, waist circumference, 6-minute walking test, exercise and food diaries). Program characteristics • the core component of the program is the ”key” factor. Every participant chooses one risk factor that they are willing to improve. This risk factor will be their “key” factor * • combining the professional and experiential knowledge • action more than lecturing (tasks, training, tests) • counselors get education (2+1+1 days) and regular meetings regular evaluation of the program • patients get a Tulppa- workbook • counselors get a Tulppa-folder + CD + extranet service *method is based on empowerment-concept and The Transtheoretical Model of Behaviour Change by DiClemente & Prochaskan Contents • • • • • • • • • artery diseases, risk factors, self-care personal risk factors ”key factor” nutrition and physical activity smoking cessation medical treatment and coverage/reimbursement of the medications pain symptom recognition and emergency situations depression and other mood issues family, relationships and sexuality Costs of the rehabilitation • Estimated costs today: 300-340 €/ patient (includes counsellor salaries, all the material and laboratory examinations) Results of the 12 month follow up study • Evaluation study • 707 rehabilitation participants – 57 % had coronary artery diease – 7,7 % had diabetes – 2,8 % had cerebrovascular disease (for example stroke or TIA) – 16,5 % had several diagnoses Results of the 12 month follow up study • 4,9 % were smokers • Middle age was 69 yrs. (men 67 yrs., women 69 yrs.) • 2 hour oral glucose tolerance test was made for 27,6 % of the patients (W=32,1%, M= 44,8 %) – Men 5,9 (median) – Women 6,8 (median) Risk factor changes in 12 months Weight BMI (N= 619) (N= 510) Waist (N=600) Systolic BP (N= 597) Diastolic BP (N= 596) Total cholesterol LDL HDL (N= 607) (N= 593) (N= 598) Triglycerides (N= 584) Fasting blood sugar 0 months 12 months p-arvo 81,4 80,6 1) .000 28,9 28,6 1) .000 98,8 97,6 1) .000 152,3 148,5 1) .000 84,2 82,9 1) .007 4,2 4,2 1) ns 2,3 2,3 1) ns 1,35 1,36 1) ns 1,35 1,34 1) ns 6,5 6,3 1) ns 491 517 * 1) .000 (N= 239) 6 min walking test* (N= 495) *6 month test 1) 2 related samples t-test 1) Risk factor changes for those who had elevated values in the beginning BMI (N= 405) Waist (N=500) Systolic BP (N= 495) Diastolic BP (N= 287) Total cholesterol 0 months 12 months p-value 30,3 30,0 1) .000 101,7 100,2 1) .000 159,1 152,1 1) .000 93,3 87,1 1) .000 5,2 5,0 1) .000 3,1 2,9 1) .000 0,86 0,94 1) .000 2,57 2,07 1) .000 7,5 6,7 1) .000 (N= 207) LDL HDL (N= 210) (N= 107) Triglycerides (N= 87) Fasting blood sugar (N= 124) 1) 2 related samples t-test 1)