Patient-Centered Care Management/Seniors/Multimorbidities

描述（由申请人提供）：多种慢性疾病给老年人带来越来越大的疾病负担，并使他们面临健康状况不佳的风险，包括身体功能下降和丧失独立性。目前的标准护理强调对个别疾病的管理，对患有多种慢性病、疾病或残疾的人来说可能不够全面。此外，慢性疾病的最佳护理在很大程度上取决于自我护理，老年人在医疗自我护理过程中遇到障碍的风险特别大。 我们建议调查的医疗保健需求和过程的老年人口与骨关节炎，糖尿病和抑郁症的三种慢性健康状况。这些条件的选择是基于其高患病率，症状和治疗的相互作用，自我管理的需要，并有可能说明，对这些条件的人的护理管理可能超过现有的疾病管理策略的总和。我们将通过电话调查确定本研究人群中存在身体功能下降和健康状况不良风险的特征，该电话调查评估了医疗自我护理的潜在障碍（如社会隔离、一种疾病的压倒性影响以及对不同疾病的相互矛盾的建议）、患者激活水平、健康素养和认知能力。然后，我们将通过一系列焦点小组对医疗保健需求进行定性探索，以补充这些信息。在凯撒医疗机构的科罗拉多地区的临床和研究领域工作，我们将利用这些信息进一步修改一个建议的护理管理过程，利用护理经理评估患者的个人护理需求，并获得适当的资源，以满足这些需求的老年人与多病。最后，我们将进行一项可行性试点干预，以测试这一修订后的护理过程，为更大规模的干预试验做准备。 如果在我们的调查中，以患者为中心的护理管理策略对患有三种疾病的人群有效，那么我们提出的策略可以外推到患有不同慢性疾病的老年人人群。鉴于越来越多的老年人患有多种医疗问题的公共卫生影响;有效和高效的护理模式，改善这一人群的健康和生活质量的结果有可能作出重大贡献的一个主要健康优先事项在美国今天。

DESCRIPTION (provided by applicant): Multimorbid chronic medical conditions present an increasing disease burden for older persons and place them at risk for poor health outcomes including decreased physical functioning and loss of independence. Current standard care that emphasizes management of individual diseases may not be sufficiently comprehensive for persons with multiple chronic conditions, diseases or disabilities. In addition, optimal care of chronic medical conditions depends heavily on self-care, and the elderly are at particular risk for experiencing barriers to the medical self-care process. We propose to investigate the medical care needs and processes of a geriatric population with the three chronic health conditions of osteoarthritis, diabetes and depression. These conditions were chosen based on their high prevalence, interactions of symptoms and treatment, need for self-management, and potential to illustrate that care management for persons with these conditions may be more than the sum of existing disease management strategies. We will identify characteristics of this study population that place them at risk for decreased physical functioning and poor health status though a telephone survey that assesses potential barriers to medical self-care (such as social isolation, overwhelming effects of one condition, and conflicting recommendations for different conditions), level of patient activation, health literacy and cognitive abilities. We will then supplement this information with a qualitative exploration of the medical care needs through a series of focus groups. Working in the clinical and research arenas of the Colorado Region of Kaiser Permanente; we will use this information to further revise a proposed care management process for seniors with multimorbidities that utilizes care managers to assess patients' individual care needs and access appropriate resources to meet these needs. Finally we will conduct a feasibility pilot intervention to test this revised process of care in preparation for a larger intervention trial. If shown to be effective for a population with the three conditions in our investigation, patient-centered care management strategies such as the one we propose may then be extrapolated to populations of older persons with different constellations of chronic medical conditions. Given the public health impact of the growing numbers of seniors with multiple medical problems; effective and efficient models of care delivery that improve health and quality of life outcomes for this population have the potential to make a substantial contribution to a major health priority in the United States today.