Collaborative management of chronic illness
Collaborative management of chronic illness
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DOI：
10.7326/0003-4819-127-12-199712150-00008
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发表时间：
1997-12-15
影响因子：
39.2
通讯作者：
Wagner, EH
中科院分区：
文献类型：
--
作者：
Von Korff, M;Gruman, J;Wagner, EH
在慢性病中，日常护理责任主要落在患者及其家人身上。与医疗保健提供者的有效合作关系可以帮助患者和家庭更好地处理自我护理任务。协作管理是加强和支持慢性病自我保健的护理，同时确保有效的医疗，预防和健康维护干预措施。本文讨论了根据行为原则和慢性病有效护理的经验证据发展起来的协作管理的以下基本要素：1）协作定义问题，其中患者定义的问题与医生诊断的医疗问题一起沿着确定; 2）目标定位、目标设定和规划，其中患者和提供者关注特定问题，设定现实的目标，并根据患者的偏好和准备情况制定实现这些目标的行动计划; 3）创建一系列自我管理培训和支持服务，患者可以获得教授实施医疗方案所需技能的服务，引导健康行为改变，并提供情感支持;以及4）积极和持续的随访，其中在指定的时间间隔内与患者联系以监测健康状况，识别潜在的并发症，并检查和加强实施护理计划的进展。这些要素构成了慢性病护理服务的共同核心，不需要为每种疾病重新设计。
In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of selfmanagement training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.