Our hospital is in the Sorachi region of Hokkaido, located in old coal mine area, where aging and depopulation is in progress. The aging rate of the Sorachi region is as high as 33%, so there is a large number of elderly people who develop heart failure. The number of patients with heart failure to be hospitalized has increased over the years and the average age of patients with heart failure has also reached about 80 years old. So we have launched heart failure medical team and cardiac rehabilitation in our hospital. Certified nurse of chronic heart failure nursing is a central personage of the team, and he also manages a nursing outpatient care. There is a large number of elderly people living alone in the area, so medical social workers of community cooperative section also have very important role in the team. Physical therapists involved in cardiac rehabilitation have increased, then cumulative total number of outpatient participating in rehabilitation and cumulative total number of units of rehabilitation have increased. There are many patients difficult to visit our hospital regularly, because our medical district is widely distributed. And there are very few hospital who have done cardiac rehabilitation in the rural area. So we think hospital and clinic cooperation and community cooperation is very important and future problem.
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