Telfer School of Management, University of Ottawa, Ottawa, Canada.
Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada.
Patient. 2023 Nov;16(6):569-578. doi: 10.1007/s40271-023-00645-8. Epub 2023 Aug 29.
The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.
慢性疾病护理模式已经指导了近 20 年的医疗保健质量改进，采用以患者为中心、疾病管理的方法来管理系统和护理团队。为了进一步推进以患者为中心的护理工作，我们建议通过目标导向型护理方法来加强慢性疾病护理模式。目标导向型护理以患者为中心，将重点放在每个人一生中最重要的事情上。患者的目标指导护理决策，这些决策是由临床医生和患者共同协商做出的。在本文中，我们以患者为中心、目标导向型护理为基础，对慢性疾病护理模式的各个要素进行扩展，并提供了如何实施这种方法的临床示例。我们讨论了这种经过调整的方法如何支持我们的医疗保健系统，特别是在多种疾病不断增加的情况下。
