Steurer-Stey Claudia, Frei Anja, Rosemann Thomas
Institut für Hausarztmedizin, Universität Zürich, Universitätsspital Zürich, Sonneggstrasse 6, 8091 Zürich.
Rev Med Suisse. 2010 May 19;6(249):1016-9.
The care of patients with chronic disease is one of the most urgent medical challenges of actual society. The chronic care model (CCM) is an organizational, proactive approach for chronic disease in primary care. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a proactive practice team. CCM identifies six essential elements of high-quality health care: community; health system; self-management support; delivery system design; decision support, and clinical information systems. The article summarizes the evidence on the CCM, the adoption and implications for successful implementation into the Swiss health care system.
慢性病患者的护理是当今社会最紧迫的医学挑战之一。慢性病护理模式（CCM）是一种在初级护理中针对慢性病的组织性、前瞻性方法。该系统在知识渊博、积极主动的患者与积极主动的医疗团队之间建立切实可行、相互支持且基于证据的互动。CCM确定了高质量医疗保健的六个基本要素：社区；卫生系统；自我管理支持；服务提供系统设计；决策支持以及临床信息系统。本文总结了有关CCM的证据、其在瑞士医疗保健系统中的采用情况及成功实施的意义。
