Klemenc-Ketis Zalika, Stojnić Nataša, Zavrnik Črt, Ružić Gorenjec Nina, Danhieux Katrien, Lukančič Majda Mori, Susič Antonija Poplas
Ljubljana Community Health Centre, Metelkova 9, 1000 Ljubljana, Slovenia.
Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Poljanski nasip 58, 1000 Ljubljana, Slovenia.
Int J Integr Care. 2021 Sep 28;21(3):15. doi: 10.5334/ijic.5637. eCollection 2021 Jul-Sep.
Research on models of integrated health care for hypertension and diabetes is one of the priority issues in the world. There is a lack of knowledge about how integrated care is implemented in practice. Our study assessed its implementation in six areas: identification of patients, treatment, health education, self-management support, structured collaboration and organisation of care.
This was a mixed methods study based on a triangulation method using quantitative and qualitative data. It took place in different types of primary health care organisations, in one urban and two rural regions of Slovenia. The main instrument for data collection was the Integrated Care Package (ICP) Grid, assessed through four methods: 1) a document analysis (of a current health policy and available protocols; 2) observation of the infrastructure of health centres, organisation of work, patient flow, interaction of patients with health professionals; 3) interview with key informants and 4) review of medical documentation of selected patients.
The implementation of the integrated care in Slovenia was assessed with the overall ICP score of 3.7 points (out of 5 possible points). The element Identification was almost fully implemented, while the element Self-management support was weakly implemented.
The implementation of the integrated care of patients with diabetes and/or hypertension in Slovenian primary health care organisations achieved high levels of implementation. However, some week points were identified.
Integrated care of the chronic patients in Slovenia is already provided at high levels, but the area of self-management support could be improved.
高血压和糖尿病综合医疗模式的研究是全球重点关注的问题之一。目前对于综合医疗在实际中的实施情况了解不足。我们的研究评估了其在六个方面的实施情况：患者识别、治疗、健康教育、自我管理支持、结构化协作及医疗组织。
这是一项采用三角测量法、结合定量和定性数据的混合方法研究。研究在斯洛文尼亚一个城市地区和两个农村地区的不同类型基层医疗组织中开展。主要的数据收集工具是综合医疗包（ICP）网格，通过四种方法进行评估：1）文件分析（当前的卫生政策和现有协议）；2）观察健康中心的基础设施、工作组织、患者流程、患者与医护人员的互动；3）与关键信息提供者进行访谈；4）查阅选定患者的医疗记录。
斯洛文尼亚综合医疗的实施情况通过ICP总得分3.7分（满分5分）进行评估。“识别”要素几乎完全实施，而“自我管理支持”要素实施力度较弱。
斯洛文尼亚基层医疗组织中糖尿病和/或高血压患者综合医疗的实施达到了较高水平。然而，也发现了一些薄弱环节。
斯洛文尼亚慢性病患者的综合医疗已达到较高水平，但自我管理支持方面仍有待改善。
