Wellingham John, Tracey Jocelyn, Rea Harold, Gribben Barry
Integrated Care Unit, Counties Manukau District Health Board, Auckland, New Zealand.
N Z Med J. 2003 Feb 21;116(1169):U327.
To develop an effective and efficient process for the seamless delivery of care for targeted patients with specific chronic diseases. To reduce inexplicable variation and maximise use of available resources by implementing evidence-based care processes. To develop a programme that is acceptable and applicable to the Counties Manukau region.
A model for the management of people with chronic diseases was developed. Model components and potential interventions were piloted. For each disease project, a return on investment was calculated and external evaluation was undertaken. The initial model was subsequently modified and individual disease projects aligned to it.
The final Chronic Care Management model, agreed in September 2001, described a single common process. Key components were the targeting of high risk patients, organisation of cost effective interventions into a system of care, and an integrated care server acting as a data warehouse with a rules engine, providing flags and reminders. Return on investment analysis suggested potential savings for each disease component from $277 to $980 per person per annum.
For selected chronic diseases, introduction of an integrated chronic care management programme, based on internationally accepted best practice processes and interventions can make significant savings, reducing morbidity and improving the efficiency of health delivery in the Counties Manukau region.
为患有特定慢性病的目标患者开发一种有效且高效的无缝护理流程。通过实施循证护理流程，减少无法解释的差异并最大限度地利用可用资源。开发一个适用于曼努考郡地区且可接受的项目。
制定了一个慢性病患者管理模型。对模型组件和潜在干预措施进行了试点。针对每个疾病项目，计算了投资回报率并进行了外部评估。随后对初始模型进行了修改，并使各个疾病项目与之保持一致。
2001年9月商定的最终慢性病护理管理模型描述了一个单一的通用流程。关键组件包括针对高风险患者、将具有成本效益的干预措施组织到护理系统中，以及一个作为带有规则引擎的数据仓库的综合护理服务器，提供警示和提醒。投资回报率分析表明，每个疾病组件每年每人可能节省277美元至980美元。
对于选定的慢性病，引入基于国际公认的最佳实践流程和干预措施的综合慢性病护理管理项目可大幅节省成本，降低发病率并提高曼努考郡地区医疗服务的效率。
