Gibbs John F, Guarnieri Ellen, Chu Quyen D, Murdoch Kenneth, Asif Arif
Department of Surgery, Hackensack Meridian Health School of Medicine at Seton Hall University, Nutley, NJ, USA.
Department of Healthcare Quality and Safety, Thomas Jefferson University College of Population Health, Philadelphia, PA, USA.
J Gastrointest Oncol. 2021 Jul;12(Suppl 2):S324-S338. doi: 10.21037/jgo-20-317.
"" (Suborne 2007). The rising rate of the global aging population is predicted to create a health care crisis within the next three decades. Vulnerable older adults suffer from multiple chronic conditions (MCCs) in addition to cognitive and physical decline during the process of aging resulting in an inability to optimally achieve self-management. In terms of resource utilization, complex inpatient, and outpatient care results in higher physician visits, polypharmacy, and higher prescription costs. Health literacy has become known as an important social determinant of health affecting the older population. Both reductions in health literacy and self-management are associated with poorer health outcomes. The patient activation measure (PAM) has been coined "a vital sign" to ascertain a patient activation level throughout the continuum of care with the introduction of an intervention's progress. In this review, we conceptualize a systematic approach of the development of a "tailored" integrated community and care team to develop a partnership in assisting senior adults with MCCs. Through this intervention the value-based chronic care model (CCM) and PAM allows for an adaptable integration between the activated patient, their caregivers, and the community. The Model for Improvement (MFI) serves as a well-recognized technique for developing and executing quality improvement strategies in this "tailored" engaged and activated individual and community care team approach in achieving health outcomes and quality of life among the vulnerable older adult population worldwide.
（苏博恩，2007年）。预计全球老龄化人口比例的上升将在未来三十年引发医疗保健危机。脆弱的老年人除了在衰老过程中出现认知和身体机能衰退外，还患有多种慢性病（MCCs），导致无法实现最佳的自我管理。在资源利用方面，复杂的住院和门诊护理导致更多的医生问诊、多种药物治疗以及更高的处方费用。健康素养已被视为影响老年人群体健康的一个重要社会决定因素。健康素养和自我管理能力的下降都与较差的健康结果相关。患者激活度量表（PAM）被称为“一项生命体征”，用于在引入干预措施的过程中，确定患者在整个护理过程中的激活水平。在本综述中，我们构思了一种系统方法，以建立一个“量身定制”的综合社区和护理团队，从而在协助患有多种慢性病的老年人方面建立合作关系。通过这种干预，基于价值的慢性病护理模式（CCM）和患者激活度量表（PAM）能够使活跃的患者、其护理人员和社区之间实现适应性整合。改进模式（MFI）是一种公认的技术，用于在这种“量身定制”的、积极参与且被激活的个人和社区护理团队方法中制定和执行质量改进策略，以实现全球脆弱老年人群体的健康结果和生活质量。
