不同国家慢性病管理模式及中国“整合式”慢性病管理模式构建

Chronic disease management approaches in various countries and design of China's “integrated”chronic disease management model

从"供方、需方和保方"3个角度总结归纳国际上5种慢性病管理模式和代表国家的实践经验,构建中国"整合式"慢性病管理模式:具有明确的服务人群,制定以基层为中心的慢性病管理路径国家指导,通过专人协调各级各学科服务提供方之间的协同,通过医保支付等激励机制"牵引"落实慢性病管理的有效执行,引入绩效管理提高慢性病管理服务质量,积极探索其他综合配套手段等。

We summarize five internationally recognized chronic disease management approaches and their typical implementation in five countries,based on a 3-aspects（provider,patient,and insurer） analysis framework. We then propose to construct an＂integrated＂chronic disease management model in China：specifying explicit targeting population,formulating grassroots-centered care pathways and national management standards,appointing dedicated individual to strengthen the cooperation among required services providers at difference tiers and of various disciplines,improving chronic disease management practice by means of incentives such as additional payment from insurance schemes and financial support,promoting the use of performance management to improve care quality,and exploring systematic supporting methods to drive the implementation of chronic disease management.