Integrated Care Models for Cancer Survivorships: Conceptual Framework, Characteristics and Implications to China

doi:10.12114/j.issn.1007-9572.2023.0803

Chinese General Practice ›› 2024, Vol. 27 ›› Issue (23): 2813-2821.DOI: 10.12114/j.issn.1007-9572.2023.0803

Special Issue: 肿瘤最新文章合辑；整合型医疗服务最新文章合辑

• Review & Perspectives • Previous Articles Next Articles

Integrated Care Models for Cancer Survivorships: Conceptual Framework, Characteristics and Implications to China

1. Department of Health Management, School of Public Health, Nantong University, Nantong 226019, China
2. Institute for Health Development, Nantong University, Nantong 226019, China
3. Department of Gastroenterology, Tumor Hospital Affiliated to Nantong University, Nantong 226001, China
4. Office of Early Detection of Cancer Program, Tumor Hospital Affiliated to Nantong University, Nantong 226001, China
5. Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin 150086, China

Received:2023-11-01 Revised:2024-01-11 Published:2024-08-15 Online:2024-01-10
Contact: WU Qunhong

癌症生存者整合型照护模式的概念框架、特征及对我国的启示

1．226019　江苏省南通市，南通大学公共卫生学院卫生事业管理学系
2．226019　江苏省南通市，南通大学卫生与健康发展研究院
3．226001　江苏省南通市，南通大学附属肿瘤医院消化肿瘤内科
4．226001　江苏省南通市，南通大学附属肿瘤医院早诊早治项目办
5．150086　黑龙江省哈尔滨市，哈尔滨医科大学卫生管理学院社会医学教研室

通讯作者: 吴群红
作者简介:
作者贡献：赵苗苗负责文章的构思与设计、论文起草，对稿件整体负责；高月霞负责文章的构思与设计、提供相关组织支持；徐燕飞负责研究资料的收集与整理；宗莉负责论文校对与修订；吴群红负责文章的质量控制及审校。
基金资助:
国家自然科学基金资助项目(72004104); 南通市卫健委科研课题(MSZ2023043); 南通大学临床医学专项项目(2022LZ011)

Abstract

Abstract:

Cancer is a significant global public health issue. With the continuous increase in cancer incidence rates and the prolonged survival time of cancer patients, the number of cancer survivors is also steadily rising. Cancer survivors face complex challenges in terms of physical, psychological, and social care, and their care services require effective coordination and integration across disciplines, sectors, and domains. Establishing integrated care model for cancer survivors has become an important strategy for addressing the challenges of survivorship care globally. However, the development of cancer survivorship care in China has been relatively lagging. This article synthesizes and summarizes the conceptual frameworks, characteristics and practical application of several representative integrated care models for survivorships. Based on China's healthcare service system, recommendations for designing and implementing integrated care strategies for cancer survivorships in China are proposed from five aspects: establishing consensus, pilot testing and exploration, workforce development, strengthening primary care, and policy support.

Key words: Cancer survivors, Integrated care models, Survivorship care system, Health services

摘要： 癌症是世界性的重大公共卫生问题。癌症发病率的持续升高以及生存时间的不断延长导致癌症生存者数量持续攀升。癌症生存者面临着身体、心理和社会照护方面的复杂挑战，其照护服务也需要跨领域、跨部门、跨学科的有效协同与整合，建立癌症生存者整合型照护模式已经成为各国应对癌症生存者照护挑战的重要策略。然而目前我国癌症生存者照护领域的发展还相对滞后。本文梳理和总结了当前代表性的癌症生存者整合型照护模式的概念框架、特征、应用以及在我国的实践进展，结合我国卫生服务体系状况，从建立共识、试点探索、人才建设、强化基层、政策支持五个方面提出相关建议，以期为我国设计与实施癌症生存者整合型照护策略提供参考和借鉴。

关键词: 癌症生存者, 整合型照护模式, 生存者照护体系, 卫生服务

CLC Number:

R 730.9

ZHAO Miaomiao,GAO Yuexia,XU Yanfei, et al. Integrated Care Models for Cancer Survivorships: Conceptual Framework, Characteristics and Implications to China[J]. Chinese General Practice, 2024, 27(23): 2813-2821. DOI: 10.12114/j.issn.1007-9572.2023.0803.
赵苗苗,高月霞,徐燕飞等. 癌症生存者整合型照护模式的概念框架、特征及对我国的启示[J]. 中国全科医学, 2024, 27(23): 2813-2821. DOI: 10.12114/j.issn.1007-9572.2023.0803.

Figures/Tables 2

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类型	模式	特征	优势	不足
组织整合	协调性照护模式	不同服务提供者之间的协调、沟通和资源共享，以促进服务的全面而连续	简化整体服务流程，提高工作效率和服务质量	对服务提供者的合作与沟通以及服务提供机构的组织协调能力要求较高
组织整合	延续性照护模式	服务在时间和地点上的连续性和稳定性，以确保患者在不同阶段均能获得必要的服务	服务的连续和协调；注重医患关系和沟通；患者满意度高	需要耗费较高的医疗照护资源和人力成本
专业整合	跨学科共享照护模式	多学科团队的协作和专业知识的共享，提供全方位的照护服务	跨学科、跨部门共同参与照护并分摊责任，减轻专科医生负担，缓解照护人力不足	涉及服务提供者的变动，医患人际连续性不足；所需要资源较多，实施难度较大
专业整合	支持性照护模式	多学科、跨部门整合，以综合关怀和个体化支持为核心，满足患者多维需求，特别是医学措施外的需求	关注患者和照护者的个性化需求，有利于优化照护资源配置；强化心理社会支持，提高生活质量	对于照护资源和人力的需求较高，资源或人力匮乏的地区难以实施
临床整合	多学科诊疗照护模式	基于临床多学科协作，为患者提供全面、协调、综合的诊疗服务	诊疗具有全面性、精准性和个性化；简化诊疗流程，避免患者多次转诊、反复检查	对诊疗效果之外的服务关注较少；均对医疗专业水平要求高；成本和费用较高
临床整合	共享门诊模式	集多个学科医生团队和资源，在同一个门诊环境下为多名患者提供综合服务	提高工作效率；可以形成支持网络；减少等待时间的同时延长医患接触时间	目前仅适用于门诊诊疗环节；患者存在隐私担忧，接受程度受限

类型	模式	特征	优势	不足
组织整合	协调性照护模式	不同服务提供者之间的协调、沟通和资源共享，以促进服务的全面而连续	简化整体服务流程，提高工作效率和服务质量	对服务提供者的合作与沟通以及服务提供机构的组织协调能力要求较高
组织整合	延续性照护模式	服务在时间和地点上的连续性和稳定性，以确保患者在不同阶段均能获得必要的服务	服务的连续和协调；注重医患关系和沟通；患者满意度高	需要耗费较高的医疗照护资源和人力成本
专业整合	跨学科共享照护模式	多学科团队的协作和专业知识的共享，提供全方位的照护服务	跨学科、跨部门共同参与照护并分摊责任，减轻专科医生负担，缓解照护人力不足	涉及服务提供者的变动，医患人际连续性不足；所需要资源较多，实施难度较大
专业整合	支持性照护模式	多学科、跨部门整合，以综合关怀和个体化支持为核心，满足患者多维需求，特别是医学措施外的需求	关注患者和照护者的个性化需求，有利于优化照护资源配置；强化心理社会支持，提高生活质量	对于照护资源和人力的需求较高，资源或人力匮乏的地区难以实施
临床整合	多学科诊疗照护模式	基于临床多学科协作，为患者提供全面、协调、综合的诊疗服务	诊疗具有全面性、精准性和个性化；简化诊疗流程，避免患者多次转诊、反复检查	对诊疗效果之外的服务关注较少；均对医疗专业水平要求高；成本和费用较高
临床整合	共享门诊模式	集多个学科医生团队和资源，在同一个门诊环境下为多名患者提供综合服务	提高工作效率；可以形成支持网络；减少等待时间的同时延长医患接触时间	目前仅适用于门诊诊疗环节；患者存在隐私担忧，接受程度受限

Integrated Care Models for Cancer Survivorships: Conceptual Framework, Characteristics and Implications to China

癌症生存者整合型照护模式的概念框架、特征及对我国的启示

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