Department of Social Psychology and Methodology, Faculty of Psychology, Autonomous University of Madrid, Spain.
Physiology Division, Otto Loewi Center of Vascular Biology, Immunity and Inflammation, Medical University of Graz, Graz, Austria,
Clin Interv Aging. 2018 Oct 23;13:2083-2095. doi: 10.2147/CIA.S177286. eCollection 2018.
Current trends in health care delivery and management such as predictive and personalized health care incorporating information and communication technologies, home-based care, health prevention and promotion through patients' empowerment, care coordination, community health networks and governance represent exciting possibilities to dramatically improve health care. However, as a whole, current health care trends involve a fragmented and scattered array of practices and uncoordinated pilot projects. The present paper describes an innovative and integrated model incorporating and "assembling" best practices and projects of new innovations into an overarching health care system that can effectively address the multidimensional health care challenges related to aging patient especially with chronic health issues. The main goal of the proposed model is to address the emerging health care challenges of an aging population and stimulate improved cost-efficiency, effectiveness, and patients' well-being. The proposed home-based and community-centered Integrated Healthcare Management System may facilitate reaching the persons in their natural context, improving early detection, and preventing illnesses. The system allows simplifying the health care institutional structures through interorganizational coordination, increasing inclusiveness and extensiveness of health care delivery. As a consequence of such coordination and integration, future merging efforts of current health care approaches may provide feasible solutions that result in improved cost-efficiency of health care services and simultaneously increase the quality of life, in particular, by switching the center of gravity of health delivery to a close relationship of individuals in their communities, making best use of their personal and social resources, especially effective in health delivery for aging persons with complex chronic illnesses.
当前的医疗保健服务和管理趋势，如结合信息和通信技术的预测性和个性化医疗保健、家庭护理、通过增强患者权能进行健康预防和促进、护理协调、社区卫生网络和治理，为大幅改善医疗保健提供了令人兴奋的可能性。然而，总的来说，当前的医疗保健趋势涉及到分散的、零星的实践和不协调的试点项目。本文介绍了一种创新的综合模式，将最佳实践和新创新项目“整合”到一个总体医疗保健系统中，可以有效地应对与老龄化患者特别是慢性病患者相关的多维医疗保健挑战。该模型的主要目标是应对人口老龄化带来的新医疗保健挑战，并刺激提高成本效益、效果和患者的幸福感。拟议的基于家庭和以社区为中心的综合医疗保健管理系统可以促进在自然环境中接触到患者，提高早期检测率，并预防疾病。该系统通过组织间协调简化医疗保健机构结构，增加医疗保健服务的包容性和广泛性。由于这种协调和整合，未来对当前医疗保健方法的合并努力可能会提供可行的解决方案，从而提高医疗保健服务的成本效益，同时提高生活质量，特别是通过将医疗保健提供的重心转移到个人与其所在社区的密切关系上，充分利用他们的个人和社会资源，特别是在为患有复杂慢性病的老年人提供医疗保健方面效果显著。
