【摘要】：目的:明確慢性阻塞性肺疾病(Chronic Cbstractive Pulmonary Disease,COPD)穩(wěn)定期患者整合照護(hù)模式的基本結(jié)構(gòu)與關(guān)鍵要素,提出發(fā)展策略。方法:通過(guò)文獻(xiàn)檢索,以慢病管理模型為理論框架對(duì)COPD整合照護(hù)方案相關(guān)研究進(jìn)行分析歸納。結(jié)果:共納入16篇文獻(xiàn)13項(xiàng)研究。大多數(shù)研究對(duì)象為老年人,COPD嚴(yán)重程度為中度以上;有以醫(yī)院為中心、以社區(qū)為中心兩種類別的10種整合照護(hù)模式;均包括慢病管理模型2(含)個(gè)以上維度4~12項(xiàng)組織要素:所有整合照護(hù)方案均任命了一位協(xié)調(diào)員,制定了隨訪方案;9項(xiàng)包含社區(qū)資源的整合照護(hù)方案均有決策支持,主要方式是提供臨床指南及決策過(guò)程中整合了專家資源;13項(xiàng)研究都包含患者自我管理,主要包括健康教育、行為管理及改善(10項(xiàng))。結(jié)論:COPD整合照護(hù)方案可以依據(jù)慢病管理模型構(gòu)建,建議包括至少兩個(gè)維度的4項(xiàng)組織要素。其核心內(nèi)容是任命協(xié)調(diào)人,制定隨訪方案,社區(qū)參與的照護(hù)方案必須給予決策支持。通過(guò)健康教育與包含行動(dòng)計(jì)劃的行為管理與改善支持患者自我管理。通過(guò)信息系統(tǒng)暢通醫(yī)療服務(wù)人員與患者溝通渠道。
[Abstract]:Objective: to clarify the basic structure and key elements of integrated care model in stable patients with chronic obstructive pulmonary disease (Chronic Cbstractive Pulmonary Disease,COPD), and to put forward the development strategy. Methods: through literature retrieval, the related research of COPD integrated care scheme was analyzed and summarized based on the theoretical framework of slow disease management model. Results: a total of 16 literatures and 13 studies were included. Most of the subjects were elderly, the severity of COPD was more than moderate, there were 10 kinds of integrated care models with hospital as center and community as center, and all of them included 4 or 12 organizational elements of chronic disease management model 2 (including) more than 4 dimensions: all integrated care programs appointed a coordinator and formulated a follow-up plan. Nine integrated care programs containing community resources had decision support, mainly by providing clinical guidance and integrating expert resources in the decision-making process, and 13 studies included patient self-management, including health education, behavior management and improvement (10). Conclusion: the integrated care scheme of COPD can be constructed according to the chronic disease management model, and it is suggested that there are at least four organizational elements in at least two dimensions. The core content is the appointment of focal points, the development of follow-up programs, and community-involved care programs that must support decision-making. Support patient self-management through health education and behavioral management with action plans. Through the information system, the communication channel between medical service personnel and patients is unblocked.
【作者單位】： 南方醫(yī)科大學(xué)南方醫(yī)院;
【基金】：廣東省省級(jí)科技計(jì)劃項(xiàng)目(2013B021800151)
【分類號(hào)】：R473.5

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