Bloom J R
Public Health Rep. 1978 Jan-Feb;93(1):35-40.
If we discard some of the assumptions upon which curatively oriented medical care is based, we can design models to deliver more effective services for those with chronic diseases. Assumptions to be discarded are--that disease processes can be cured through the delivery of a "magic bullet" rather than controlled through continuous surveillance, -that the physician must be an active decision maker and thus act as gatekeeper and monitor for all disease victims, and -that care for a family of consumers must be provided together. Models for the delivery of services can then be designed to provide continuity of care for those with a specific chronic disease, and paraprofessionals can be used as gatekeepers and monitors, in combination with physicians, rather than physicians alone, to give services. Models can be targeted to reach specific high-risk groups within the population at the workplace, the school, unemployment office, or wherever groups routinely congregate for purposes other than health care. Building targeted models requires extensive knowledge of the specific geographic area and its population as well as knowledge of the natural history of the disease and its treatment. For hypertension programs, goals can be set in terms of numbers of persons whose disease is controlled and the number of new programs initiated as the result of the control efforts.
如果我们摒弃一些以治愈为导向的医疗保健所基于的假设，我们就能设计出为慢性病患者提供更有效服务的模式。需要摒弃的假设包括：疾病进程可以通过提供“神奇子弹”来治愈，而非通过持续监测来控制；医生必须是积极的决策者，因此要充当所有疾病患者的把关人和监测者；以及必须同时为一群消费者提供护理。然后可以设计服务提供模式，为患有特定慢性病的患者提供持续护理，辅助专业人员可以与医生联合，而非仅由医生单独充当把关人和监测者来提供服务。这些模式可以针对工作场所、学校、失业办公室或人群因非医疗目的而经常聚集的任何地方的特定高危人群。建立针对性的模式需要对特定地理区域及其人口有广泛了解，以及对疾病的自然史及其治疗方法有了解。对于高血压项目，可以根据疾病得到控制的人数以及因控制努力而启动的新项目数量来设定目标。
