探索以病人为中心的慢性病管理模式--快乐生活俱乐部^(TM)项目报告(四)

The Happy Life Club^(TM)(4):Exploring a patient-centred approach of chronic disease management

本文是快乐生活俱乐部系列文章之四,从理论上和实践上探讨以病人为中心的医疗卫生服务模式。作者认为以病人为中心的服务是从生物-心理-社会的多维度框架中揭示疾病与患病的关系;是从医学、社会学、经济学、文化学的角度把病人理解为独特的整体人;是卫生工作者与病人、家属、社区共同分担权利和责任的过程;是医患之间富于情感互动的治疗联盟;是将医务人员客观性和主观性有机结合的服务过程。快乐生活俱乐部的设计和实施是以病人为中心为原则的,通过把动机谈话纳入糖尿病管理,来促进病人的躯体和心理健康,提高生活质量;通过培训加强健康教练的心理学技能和综合服务能力建设;鼓励健康教练与病人建立连续和长期的合作关系,共同参与和拥有糖尿病管理;着眼于给病人提供个体化的行为改变指导和帮助;通过"换帽子"的方式交替地体现临床医生和健康教练的功能。本文最后归纳了全文的要点,并提出快乐生活俱乐部的以病人为中心模式,对社区卫生服务及区域卫生系统发展的启示和意义。

The fourth article of the Happy Life Club series explores the patient-centred approach as spirit of the chronic disease management initiative.Patient-centred healthcare builds on biopsychosocial model that aims on responding patient′s needs both of physical and mental health and eventually improving quality of life;understands patient as a whole person;collaborating between supply side and demand side through changing patient-doctor relationship from egalitarian to guiding approach;and uses psychotherapeutic skills as essential for personalised service and effective health outcome.Patient-centeredness is spirit of the Happy Life Club that adding motivational interviewing into routine clinical diabetes management and promoting improvement of quality of life through assisting change behaviours.Physical,mental and social health is considered during patient assessment,intervention implementation and evaluation.Health coach and participant are encouraged to share responsibility,jointly own diabetes management and involve in quality improving activity.Trained health coach applies processes of behaviour change in individualized coaching service.In addition,health coach is encouraged jointly use medical and psychological skills in routine service.The final part of the article is to explore implications of the Happy Life Club spirit on regional community health and general practice development.