COPD患者整合照护模式分析及相关策略研究

Analysis of integrated healthcare model for Chronic Obstructive Pulmonary Disease patients

目的:明确慢性阻塞性肺疾病(Chronic Cbstractive Pulmonary Disease,COPD)稳定期患者整合照护模式的基本结构与关键要素,提出发展策略。方法:通过文献检索,以慢病管理模型为理论框架对COPD整合照护方案相关研究进行分析归纳。结果:共纳入16篇文献13项研究。大多数研究对象为老年人,COPD严重程度为中度以上;有以医院为中心、以社区为中心两种类别的10种整合照护模式;均包括慢病管理模型2(含)个以上维度4~12项组织要素:所有整合照护方案均任命了一位协调员,制定了随访方案;9项包含社区资源的整合照护方案均有决策支持,主要方式是提供临床指南及决策过程中整合了专家资源;13项研究都包含患者自我管理,主要包括健康教育、行为管理及改善(10项)。结论:COPD整合照护方案可以依据慢病管理模型构建,建议包括至少两个维度的4项组织要素。其核心内容是任命协调人,制定随访方案,社区参与的照护方案必须给予决策支持。通过健康教育与包含行动计划的行为管理与改善支持患者自我管理。通过信息系统畅通医疗服务人员与患者沟通渠道。

Objective ： The aim of this paper is to identify the basic organizational structure and the key elements of integrated heahheare model of patients with Chronic Obstructive Pulmonary Disease （COPD） and propose an appro- priate development strategy. Methods： Based on the literature review of research articles about integrated care on pa- tients with COPD, an analysis was conducted with the help of the Chronic Care Model （CCM） which is a chronic dis- ease management model. Results ： From of a total 16 articles about 13 case studies were found. An integrated healthcare of COPD was carried out in 10 hospital-based or community-based care programs. Most of the patients were the elderly and health status were moderately severe or more severe. The components of healthcare programs varied from 4 to 12 in- cluded at least two CCM dimension. A coordinator or a case manager was appointed in all healthcare programs and a follow-up plan was made as well. Decision making was supported by clinic guideline grated heahhcare programs which community facilities involved. All programs included and specialist resource in 9 inte- self-management with health ed- ucation and individualized behavioral support was in 10 programs. The action plan was applied in 8 studies. 8 studies using a clinical information system connected health care provider and patients. Conclusions： COPD integrated care program can be constructed according to the management model of chronic disease, and it is suggested that we can or- ganize the COPD integrated care program based on CCM and the program comprises 4 organizational components of at least two CCM dimensions. The key elements of COPD integrated healthcare are to appoint a coordinator, to make a fol- low-up plan, and the necessity of community participation to support decision making, support self-management by edu- cation and individualized behavioral management with an action plan.