The continuous increase in the prevalence of comorbidities has severe challenges to population health management,and the World Health Organization(WHO)recommends the development of integrated medical care models to cope with the pressure of health management of patients with comorbidities.In this paper,we constructed an integrated management model for geriatric comorbidities under medical association based on PDSA theory,in order to continuously improve the management ability and effect in the reciprocal cycle of"plan-execute-research-act".The model consists of four key elements,including management team,management process,management tools and management effect.Based on previous intervention research,the model integrates patient-centered care,multidisciplinary team,patient self-management and other intervention methods,and relies on big data technology to establish a decision support platform,thus realizing the whole life cycle health management of patients with comorbidities.
关键词
共病/多种慢性病共存状况/老年人/整合管理模式/PDSA/医联体/自我管理/个案管理
Key words
Multimorbidity/Multiple chronic health conditions/Aged/Integrated care model/PDSA/Medical combination/Self-management/Case management
维普
万方数据