Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
JAMA. 2010 Nov 3;304(17):1936-43. doi: 10.1001/jama.2010.1623.
Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.
患有多种慢性健康问题和复杂医疗需求的老年患者的医疗服务常常是碎片化的、不完整的、低效的和无效的。本文描述了一位老年女性的案例，她的病情不能仅通过诊断和治疗她的个体疾病的常规方法得到有效管理。基于对现有证据的专家共识，本文确定了 4 种主动的、持续的流程，这些流程可以极大地改善患有多种慢性疾病的社区居住老年患者的初级保健：全面评估、基于证据的护理计划和监测、促进患者和（家庭照顾者）积极参与护理，以及协调专业人员为患者提供护理——所有这些都根据患者的目标和偏好进行定制。本文简要描述了包含这些流程的三种慢性护理模式，这些模式似乎改善了复杂初级保健的有效性和效率的某些方面——老年人评估和护理资源（GRACE）模式、指导护理和老年人全面关怀计划（PACE），并讨论了实施这些模式的步骤。
