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

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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