Development of the Chronic Care delivery Model focused on preventing aggravation of chronic illness

为防止高危患者病情恶化，开发了一种慢性病护理提供模式，作为疾病管理系统。该模型被应用于医院，以便将其纳入医院系统。根据这一模式，通过筛查表选择高危患者，并从住院和门诊转诊到由本研究人员开发的慢性护理专科。提供患者教育和病例管理，并在社区中寻求与初级医生的合作。该模式在两家职能不同的医院实施。结果表明，该模型适用于临床实践，有助于预防疾病的恶化。

A model was developed, as a disease management system, for chronic illness care delivery with a view to preventing aggravation of high-risk patients' conditions. The model was applied to hospitals so that it could be included in the hospital system. According to this model, high-risk patients are selected by using a screening sheet and are referred from inpatient and outpatient units to a chronic care specialized section developed by the present researchers. Patient education and case management are provided and collaboration with primary physicians is sought in a community. The model was implemented to two hospitals whose functions differed from each other. As a result, the model was demonstrated to be applicable to clinical practice, contributing to prevention of disease aggravation