基于患者全程管理模式的肺癌专病管理师岗位设置与效果评价

Post setting of lung cancer specialist disease manager based on the integrated care management model

目的:探索设置肺癌专病管理师对肺癌患者实施全程管理的可行性与效果,为慢性病患者的规范管理提供参考依据。方法:通过建立患者全程管理中心,设立专病管理师岗位,对肺癌患者实施全程管理模式,并对入组患者的活检筛查结果、随访依从率、诊疗完成率、自我管理能力及满意度进行调查分析。结果:设立岗位1年以来,累计登记入组患者5?576例,行纤维支气管镜活检者186例,其中活检筛查恶性比例为91.9%,高于实施前比例(35.3%)(P<0.001),各时间段随访依从率均为100.0%,医疗护理服务完成率为95.3%,患者自我管理得分从(7.98±2.34)分提升至(9.42±1.63)分(P<0.001),总体满意度为96.3%。结论:肺癌患者全程管理模式实现了肺结节的早期精准识别、肺癌风险的周期评估与肺癌诊疗的规范管理,提升了患者的自我管理能力和就诊满意度。肺癌专病管理师岗位的设置,为规范慢性病患者管理、丰富护理学科内涵提供了新的思路。

Objective:To explore the feasibility and effects of setting up a post of lung cancer specialist disease manager in the management of lung cancer patients.Methods:Through the establishment of a integrated care management center and the specialist disease manager positions,the integrated care management model was implemented for patients with lung cancer.The biopsy screening for malignancy,follow-up compliance rate,diagnosis and treatment completion rate,self-management ability and satisfaction of the enrolled patients were investigated and analyzed.Results:Since the establishment of the post 1 year ago,a total of 5576 patients were enrolled.Among the 186 patients who underwent fiberotic bronchoscopy,the rate of biopsy screening for malignancy was 91.9%,which was significantly higher than the rate before the implementation(35.3%,P<0.001).The follow-up compliance rate in each time period was 100.0%.The medical care service completion rate was 95.3%.Patient self-management score increased from 7.98±2.34 to 9.42±1.63(P<0.001)and the overall satisfaction rate was 96.3%.Conclusion:The integrated care management model for patients with lung cancer can identify lung nodules early and accurately,assess the lung cancer risk and standardize management of lung cancer treatment,improve patients'self-management ability,and increase patients'satisfaction.The post setting of lung cancer specialist manager provides new ideas for standardizing the management of patients with chronic disease and enriches the connotation of nursing disciplines.