COPD患者整合照护模式分析及相关策略研究

发布时间：2019-08-07 20:04

【摘要】：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。
[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.
【作者单位】：南方医科大学南方医院;
【基金】：广东省省级科技计划项目(2013B021800151)
【分类号】：R473.5

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