Maastricht has a unique position in the care of the chronically ill / disease management. Based on the good agreement between the 1st and 2nd line and the use of specialist nurses in general practice, multidisciplinary care delivered in close cooperation with home care. Patient care and research in this area have yielded much appreciation and awareness in recent years. This concern extends across different disciplines.

Asthma and COPD

Within the azM a lung and pulmonary nurse may be consulted for the COPD patient group. Chain through the clinic, which takes place Huisartsenpost, since October 1, 2008 The GP these patients.

The work of the team consist of:

  • Medical diagnostics.
  • Psychosocial diagnosis.
  • Coordination of treatment.
  • The pulmonary nurse takes the training of (new) nurses accounted for and can be consulted by practice nurses.

Other tasks of the transmural pulmonary nurse are:

  • Nursing training against other providers involved in the care of execution Asthma and COPD.
  • Participation in scientific research and healthcare innovation.

For further information: Marleen Vaassen tel: 06-47268733



Diabetes nurses are consulted. Both the Maastricht UMC + and in the general practice Education, healthcare innovation, consultation and expertise are the core of the professional. It has good cooperation with the counselors / agencies concerned inseparable.

  • azM / Maastricht UMC +
    Within azM / Maastricht UMC + 4 working diabetes nurses, whose first child diabetes. Their activities include consultation management in patients with diabetes in the various wards and keeping office hours and telephone consultation in the outpatient internal medicine.

  • First line
    The largest group of diabetes nurses working in primary health care in the region of Maastricht and hills. They work closely with GPs and practice nurses.

    The nursing tasks:

  • Nursing history, relevant physical examination, diagnosis and treatment.
  • Education, lifestyle, education and instructional tools with the aim of optimizing self-management.
  • Telephone consultation.
  • Consult Lining both in general practice during home visits and in the outpatient department and wards of the University Hospital Maastricht / Maastricht UMC +.
  • Use of (para) medical care.
  • Nursing training against other providers involved in the care of diabetes.
  • Participation in research and care innovation Attn chronically ill.

The medical tasks
Tasks are taken over by doctors nurses, where this can be justified by task redistribution in health care:

  • Conducting audits year.
  • Set on antidiabetic medication.
  • Adjust antihypertensive medication.
  • Adjusting cholesterol-lowering medications.

Further information: Ms. B. Jöbses-Penders, tel: 043-3875669 Diabetes Maastricht



Geriatric care practices by the University Hospital Maastricht / Maastricht UMC + supplied mainly takes place in the home. Patients can be registered for a geriatric consultation by the general practitioner or specialist. The team consists of the geriatric internist geriatrician, geriatric nurse specialist transmural care and specialized nursing clinical care. The questions that most patients are seen by the geriatric team are:

  • Medical diagnostics.
  • Psychosocial problems.
  • Care Analysis and care coordination.
  • A combination of these.

Depending on the question, the patient can be pre-clinical, clinical and post-clinical seen by the internist-geriatrician, or by the geriatric nurse, or by both. Given the complexity of the problem will always be consultation between the doctor and the nurse regarding the policy. The goal we strive for the patient as long as possible to maintain. The home For this must be. Brought in respect of the care at the highest possible level of self-reliance and functionality This result we are trying to achieve through medical interventions in combination with drawing up a care plan. This care plan is guided so far until the desired result is achieved.

For further information: T. Martens, Specialist Nurse Geriatrics
Tel. 043-3877540


Heart failure

The care of patients with heart failure takes place in the heart failure outpatient clinic and from the managed care department. The care is provided by three cardiologists and heart failure eight heart failure nurses.

The office hours at the clinic are performed by a heart failure nurse in collaboration with a cardiologist. Moreover, there is the possibility of home visits by severely ill patients with heart failure. Play the severity of heart failure, as well as the instability and mobility play a role. In patients who are visited at home, there is close collaboration with the GP.

As part of the care patients are guided in their home environment through a remote guidance system (the Health Buddy ®). Patients are expected to use the system on their agreed manner. Use of the system means that they introduce information relating to their state, so that the health care providers in question at the level of the most up-to-date state, so that if necessary, the treatment can be adjusted. In addition, patients are supported in their self-care and can prevent patients should be. Recorded by early therapy adjustments From 2007-2010, in collaboration with the University of Maastricht and Heerlen and Sittard hospitals, made a scientific study of the effects of remote supervision. It was demonstrated that patients had fewer hospitalizations for heart failure were less anxious and less signs of depression showed, had exhibited about their disease and better self-care more knowledge. A better self-care means that a patient knows how to recognize threatening to go wrong, and at the right time asks for the help of a professional.

The function of the heart failure nurses consisting of medical and nursing tasks.

The nursing tasks are:

  • Daily telephone consultation.
  • Outpatient contacts with patients.
  • Home visits to patients.
  • Patient education about the disease, and treatment regimen.
  • Support for informal care.
  • Enabling paramedical care.
  • Enabling palliative care.
  • Support fellow patients.
  • Supervision during rehabilitation and follow-up of patients through the Health Buddy.

The heart failure nurse also plays a role in the provision of education to healthcare institutions and students and provide assistance to ensure scientific, medical and nursing research.

The medical tasks are:

  • Substitution of medical practice, is aimed at monitoring the filling state and consists of taking a medical history and perform a physical examination and if necessary apply for additional research.
  • Furthermore, the failure nurse a role in treatment, particularly in the adjustment of medication in over-or under-filling and titrating medications to achieve. Optimal treatment in a limited time frame

The goal of care for patients with heart failure is to aim that patients have a good quality of life, in which a decrease occurs in the number of hospitalizations and shortening the hospital stay.

For more information:

Josiane Boyne,
Nursing Specialist Heart Failure / researcher
Tel. 043-3875392
e-mail: j.boyne @



A neuro-oncology nurse is specially appointed for the management of patients with a tumor in the central nervous system (the brains and spinal cord). This nurse works closely with the neurologist and other medical specialists involved in the treatment process. She / he is responsible for education and information and also devotes she / he attention to the psychological and social problems that can occur in patients with a brain tumor.

Patients, families and caregivers can all subjects with the disease or the treatment to deal with the neuro-oncology nurse visit, both during and after shooting. In particular, it is referred to:

  • Questions about the treatments, examinations, surgery and medicine.
  • How and when the investigations will take place?
  • What should I do or not after surgery?
  • What side effects can I expect from the treatments and medications?
  • Information about patient.
  • Also, mediation and use of other care providers such as social work, dietitian or psychologist.

The nursing consultation
On Thursday from 14:00 to 17:00. Patients by the neurologist, neurosurgeon, oncologist or radiation oncologist referred to the nursing consultation. Also, family and caregivers are welcome. The consultation can be visited before or after visiting the doctor, or an appointment can be made.

The nursing consultation takes place in the Oncology Center.

Telephone consultation on Monday 10:00 to 11:00 hours (through the general telephone number of the University Hospital Maastricht / Maastricht UMC + 043-3876543 and ask for the signal 5260).



The nurse takes care of rheumatic patients, particularly in the hospital instead. AzM / Maastricht UMC + this is done through surgeries a nursing consultant rheumatism. There may also be a home visit to be charged when it is needed. The nurse consultant provides additive arthritis care (care aspects of care) in patients with rheumatic diseases, such as:

  • Information on disease, regimen, treatment.
  • Guidance and support in arranging resources or facilities.
  • Spray Instruction.
  • Provide group education.
  • Giving self-management courses etc.

Other tasks include:

  • Coordination of care for certain treatments (Remicade).
  • Organizational aspects of care (eg controlling MTX according to protocol).
  • Supporting the diagnosis of fibromyalgia. In the research context
  • Provide education to fellow nurses and medical students.

The procedure of reference
Patients are referred by medical specialists (rheumatologists, rehabilitation specialists, internists, orthopedic surgeons), by doctors, by paramedics (occupational therapists, physiotherapists) or others (patient, peers).

Patients may also contact you.

For more information:
Mr. M. Elmacioglu
rheumatism nursing consultant
tel 043-3876502
E-mail address: @ reumaconsulent.rvetz

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