Construction of an Integrated Management Model for Geriatric Comorbidities under Medical Association Based on PDSA Theory

doi:10.12114/j.issn.1007-9572.2023.0374

Abstract

Abstract:

The continuous increase in the prevalence of comorbidities has severe challenges to population health management, and the World Health Organization (WHO) recommends the development of integrated medical care models to cope with the pressure of health management of patients with comorbidities. In this paper, we constructed an integrated management model for geriatric comorbidities under medical association based on PDSA theory, in order to continuously improve the management ability and effect in the reciprocal cycle of "plan-execute-research-act". The model consists of four key elements, including management team, management process, management tools and management effect. Based on previous intervention research, the model integrates patient-centered care, multidisciplinary team, patient self-management and other intervention methods, and relies on big data technology to establish a decision support platform, thus realizing the whole life cycle health management of patients with comorbidities.

Key words: Multimorbidity, Multiple chronic health conditions, Aged, Integrated care model, PDSA, Medical combination, Self-management, Case management

摘要：

共病患病率的持续升高为人群健康管理带来了严峻挑战，世界卫生组织建议开发整合医疗照护模式应对共病人群健康管理压力。本文构建了一种基于PDSA理论的医联体下老年共病整合管理模式，以期在"计划-执行-学习-反馈"的往复循环中不断提升管理能力和效果。该模式由管理团队、管理流程、管理工具、管理效果4大关键要素组成。该模型在既往干预研究的基础上整合以患者为中心、多学科团队、患者自我管理等干预方式，依托大数据技术建立决策支持平台，实现共病患者的全生命周期健康管理。

关键词: 共病, 多种慢性病共存状况, 老年人, 整合管理模式, PDSA, 医联体, 自我管理, 个案管理

ZHOU Xuan,ZHANG Dan. Construction of an Integrated Management Model for Geriatric Comorbidities under Medical Association Based on PDSA Theory[J]. Chinese General Practice, 2024, 27(02): 192-200. DOI: 10.12114/j.issn.1007-9572.2023.0374.
周璇,张丹. 基于PDSA理论构建医联体下老年共病整合管理模式[J]. 中国全科医学, 2024, 27(02): 192-200. DOI: 10.12114/j.issn.1007-9572.2023.0374.

Figures/Tables 3

References 72

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