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罗伯特·伍德·约翰逊基金会糖尿病倡议中慢性病管理的持续随访与支持。

Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative.

作者信息

Fisher Edwin B, Brownson Carol A, O'Toole Mary L, Anwuri Victoria V

机构信息

The School of Public Health, University of North Carolina at Chapel Hill (Dr Fisher)

The National Program Office of the Robert Wood Johnson Foundation Diabetes Initiative, Division of Health Behavior Research, Departments of Internal Medicine and Pediatrics, Washington University School of Medicine, St Louis, Missouri (Ms Brownson, Dr O’Toole, Ms Anwuri)

出版信息

Diabetes Educ. 2007 Jun;33 Suppl 6:201S-207S. doi: 10.1177/0145721707304189.

DOI:10.1177/0145721707304189
PMID:17620402
Abstract

PURPOSE

The purpose of this article is to identify approaches to providing ongoing follow-up and support for diabetes self-management based on the experience of 14 self-management projects of the Diabetes Initiative of the Robert Wood Johnson Foundation.

METHODS

This study is a collaboration with grantees of the Diabetes Initiative of the Robert Wood Johnson Foundation, a program focused on diabetes self-management in primary care and community settings. Grantees and national program staff identified key functions that ongoing follow-up and support need to fill and key features of programs that do so.

RESULTS

Key functions of ongoing follow-up and support include monitoring of status and self-management, encouragement and facilitation of regular clinical care, encouragement and motivation of self-management, and facilitating skills for coping with changes in circumstances or emergent problems. Key features of ongoing follow-up and support to fill these functions are being available on demand; being proactive in maintaining contact and preventing individuals from "falling between the cracks"; having personal, motivational, and consistent key messages; not being limited to diabetes; and being inclusive of a wide range of resources and settings.

CONCLUSIONS

Initial characterization of key features of ongoing follow-up and support has been accomplished. This should facilitate research to clarify how it may best be provided and systematic approaches to doing so. These should lead to health service and policy initiatives supporting this critical dimension of programs to promote self-management and lifelong healthy living patterns.

摘要

目的

本文旨在根据罗伯特·伍德·约翰逊基金会糖尿病倡议的14个自我管理项目的经验,确定为糖尿病自我管理提供持续随访和支持的方法。

方法

本研究是与罗伯特·伍德·约翰逊基金会糖尿病倡议的受资助者合作进行的,该项目专注于初级保健和社区环境中的糖尿病自我管理。受资助者和国家项目工作人员确定了持续随访和支持需要履行的关键职能以及履行这些职能的项目的关键特征。

结果

持续随访和支持的关键职能包括监测状况和自我管理、鼓励和促进定期临床护理、鼓励和激发自我管理以及促进应对情况变化或突发问题的技能。履行这些职能的持续随访和支持的关键特征包括随需可用;积极保持联系并防止个人“被忽视”;拥有个性化、激励性和一致的关键信息;不限于糖尿病;并包含广泛的资源和环境。

结论

已完成对持续随访和支持的关键特征的初步描述。这应有助于开展研究,以阐明如何最好地提供持续随访和支持以及这样做的系统方法。这些研究应促成卫生服务和政策倡议,以支持促进自我管理和终身健康生活模式的项目的这一关键层面。

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