Development of the new chronic disease care provision model by expanding roles of nurses and medical insurance holders

在这项研究中，实施了一个项目，以防止慢性疾病的进展。为了实现这一目标，我们确保了对慢性病患者护理的连续性，采用了分层逻辑，允许适当分配医疗资源，并设计和开发了慢性病护理提供模式。该模式提供基于证据的护理。更具体地说，成立了疾病管理中心，为医疗保险持有人和医疗机构提供支持，并派驻了受过专业教育的护士。此外，还对医疗保险持有人群体进行了分层，并制定了疾病管理方案，认为这对每个阶层都是必要的。因此，建立了一个从初级预防到三级预防的机制。

In this study, a project was implemented to prevent progression of chronic diseases. In order to achieve this, continuity of care for chronic disease patients was secured, stratified logic was utilized which allowed for appropriate allocations of medical resources, and a Chronic Disease Care Provision Model was designed and developed. The model offers evidence-based care.More specifically, a disease management center was set up, which supported medical insurance holders and medical institutions and where nurses with specialized education were stationed. Moreover, the group of medical insurance holders was stratified and a disease management program was formulated, which was deemed to be necessary for each stratum. Thus, a mechanism was built in order to cover from primary to tertiary prevention.