Martin Carmel M, Peterson Chris
Department of Family Medicine, Northern Ontario School of Medicine, Ottawa, Canada.
Aust Fam Physician. 2008 Mar;37(3):161-4.
Chronic illness is increasingly being recognised as a widespread, debilitating and costly burden. Most models of care used in the acute care setting are inappropriate for chronic illness and are costly.
This article examines the goals of chronic illness care in the Australian general practice context and related issues from a conceptual perspective. It describes developments in care planning in Australia, particularly Medicare payments for care planning, and discusses how such developments can assist general practitioners in patient care. A case study of an Aboriginal patient with chronic illness is described to illustrate the issues discussed.
Care planning/management based on a partnership model can bring about some success in management, even with the most difficult cases. Illness support, management of rest of life conditions and treatment and self management of disease are required. Care planning/management items, as part of the Enhanced Primary Care program provide incentive payments to address key models of improving complex chronic care. This can result in improved system organisation and self management of chronic illness.
慢性病日益被视为一种广泛存在、使人衰弱且成本高昂的负担。急性护理环境中使用的大多数护理模式不适用于慢性病，且成本高昂。
本文从概念角度审视澳大利亚全科医疗环境下慢性病护理的目标及相关问题。它描述了澳大利亚护理计划的发展情况，特别是医疗保险对护理计划的支付，并讨论了这些发展如何协助全科医生进行患者护理。文中描述了一名患有慢性病的原住民患者的案例研究，以说明所讨论的问题。
基于伙伴关系模式的护理计划/管理即使在处理最困难的病例时，也能在管理方面取得一些成功。需要疾病支持、对余生状况的管理以及疾病的治疗和自我管理。作为强化初级护理计划一部分的护理计划/管理项目提供激励性支付，以应对改善复杂慢性病护理的关键模式。这可带来系统组织的改善和慢性病的自我管理。
