基于PDSA理论构建医联体下老年共病整合管理模式

doi:10.12114/j.issn.1007-9572.2023.0374

摘要/Abstract

摘要： 共病患病率的持续升高为人群健康管理带来了严峻挑战，世界卫生组织建议开发整合医疗照护模式应对共病人群健康管理压力。本文构建了一种基于PDSA理论的医联体下老年共病整合管理模式，以期在"计划-执行-学习-反馈"的往复循环中不断提升管理能力和效果。该模式由管理团队、管理流程、管理工具、管理效果4大关键要素组成。该模型在既往干预研究的基础上整合以患者为中心、多学科团队、患者自我管理等干预方式，依托大数据技术建立决策支持平台，实现共病患者的全生命周期健康管理。

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

Abstract:

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.

Key words: Multimorbidity, Multiple chronic health conditions, Aged, Integrated care model, PDSA, Medical combination, Self-management, Case management

周璇,张丹. 基于PDSA理论构建医联体下老年共病整合管理模式[J]. 中国全科医学, 2024, 27(02): 192-200. DOI: 10.12114/j.issn.1007-9572.2023.0374.
ZHOU Xuan,ZHANG Dan. Construction of an Integrated Management Model for Geriatric Comorbidities under Medical Association Based on PDSA Theory[J]. Chinese General Practice, 2024, 27(02): 192-200. DOI: 10.12114/j.issn.1007-9572.2023.0374.

图/表 3

图1 老年共病患者整合管理模型注：GIT=老年医学多学科整合团队。

Figure 1 An integrated management model for geriatric comorbidities

图2 GIT团队组织架构图

Figure 2 GIT team organization chart

图3 老年共病患者整合管理模式流程图注：MDT=多学科诊疗团队。

Figure 3 Flow chart of the integrated management model for older patients with comorbidities

参考文献 72

[1]	ALMIRALL J，FORTIN M. The coexistence of terms to describe the presence of multiple concurrent diseases[J]. J Comorb，2013，3：4-9. DOI：10.15256/joc.2013.3.22.
[2]	FROST R，RAIT G，WHEATLEY A，et al. What works in managing complex conditions in older people in primary and community care? A state-of-the-art review[J]. Health Soc Care Community，2020，28（6）：1915-1927. DOI：10.1111/hsc.13085.
[3]	ZHOU X，ZHANG D. Multimorbidity in the elderly：a systematic bibliometric analysis of research output[J]. Int J Environ Res Public Health，2021，19（1）：353. DOI：10.3390/ijerph19010353.
[4]	曹丰，王亚斌，薛万国，等. 中国老年疾病临床多中心报告[J].中华老年多器官疾病杂志，2018，17（11）：801-808.
[5]	CHATTERJI S，BYLES J，CUTLER D，et al. Health，functioning，and disability in older adults—present status and future implications[J]. Lancet，2015，385（9967）：563-575. DOI：10.1016/S0140-6736(14)61462-8.
[6]	GLYNN L G，VALDERAS J M，HEALY P，et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost[J]. Fam Pract，2011，28（5）：516-523. DOI：10.1093/fampra/cmr013.
[7]	LUGTENBERG M，BURGERS J S，CLANCY C，et al. Current guidelines have limited applicability to patients with comorbid conditions：a systematic analysis of evidence-based guidelines[J]. PLoS One，2011，6（10）：e25987. DOI：10.1371/journal.pone.0025987.
[8]	RIJKEN M，HUJALA A，VAN GINNEKEN E，et al. Managing multimorbidity：profiles of integrated care approaches targeting people with multiple chronic conditions in Europe[J]. Health Policy，2018，122（1）：44-52. DOI：10.1016/j.healthpol.2017.10.002.
[9]	WHITE B. Improving chronic disease care in the real world：a step-by-step approach[J]. Fam Pract Manag，1999，6（9）：38-43.
[10]	WHO. Global Strategy on People Centered Integrated Health Services，2015[EB/OL]. [2023-05-02].
[11]	ONDER G，PALMER K，NAVICKAS R，et al. Time to face the challenge of multimorbidity. A European perspective from the joint action on chronic diseases and promoting healthy ageing across the life cycle （JA-CHRODIS）[J]. Eur J Intern Med，2015，26（3）：157-159. DOI：10.1016/j.ejim.2015.02.020.
[12]	MATEO-ABAD M，FULLAONDO A，MERINO M，et al. Impact assessment of an innovative integrated care model for older complex patients with multimorbidity：the CareWell Project[J]. Int J Integr Care，2020，20（2）：8. DOI：10.5334/ijic.4711.
[13]	FERNÁNDEZ MOYANO A，MACHÍN LÁZARO J M，MARTÍN ESCALANTE M D，et al. Care models for polypathological patients[J]. Rev Clin Esp，2017，217（6）：351-358. DOI：10.1016/j.rce.2017.03.003.
[14]	HÉBERT R，DURAND P J，DUBUC N，et al. PRISMA：a new model of integrated service delivery for the frail older people in Canada[J]. Int J Integr Care，2003，3：e08. DOI：10.5334/ijic.73.
[15]	JOHN J R，TANNOUS W K，JONES A. Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia[J]. Health Qual Life Outcomes，2020，18（1）：288. DOI：10.1186/s12955-020-01539-1.
[16]	LAI Y F，LEE S Y F，XIONG J，et al. Challenges and opportunities in pragmatic implementation of a holistic hospital care model in Singapore：a mixed-method case study[J]. PLoS One，2021，16（1）：e0245650. DOI：10.1371/journal.pone.0245650.
[17]	SMITH S M，WALLACE E，O'DOWD T，et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings[J]. Cochrane Database Syst Rev，2021，1（1）：CD006560. DOI：10.1002/14651858.CD006560.pub4.
[18]	DAMERY S，FLANAGAN S，COMBES G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews[J]. BMJ Open，2016，6（11）：e011952. DOI：10.1136/bmjopen-2016-011952.
[19]	DAMBHA-MILLER H，SIMPSON G，HOBSON L，et al. Integrated primary care and social services for older adults with multimorbidity in England：a scoping review[J]. BMC Geriatr，2021，21（1）：674. DOI：10.1186/s12877-021-02618-8.
[20]	TORTAJADA S，GIMÉNEZ-CAMPOS M S，VILLAR-LÓPEZ J，et al. Case management for patients with complex multimorbidity：development and validation of a coordinated intervention between primary and hospital care[J]. Int J Integr Care，2017，17（2）：4. DOI：10.5334/ijic.2493.
[21]	MOLINO C G，ROMANO-LIEBER N S，RIBEIRO E，et al. Non-communicable disease clinical practice guidelines in Brazil：a systematic assessment of methodological quality and transparency[J]. PLoS One，2016，11（11）：e0166367. DOI：10.1371/journal.pone.0166367.
[22]	杨立成，鲍琳辉，田义娟，等.医联体模式下构建双向转诊机制的探讨[J].中国医院，2015，19（7）：33-35.
[23]	BERWICK DM. Developing and testing changes in delivery of care[J]. Ann Intern Med，1998，128（8）：651-656. DOI：10.7326/0003-4819-128-8-199804150-00009.
[24]	REED J E，CARD A J. The problem with Plan-Do-Study-Act cycles[J]. BMJ Qual Saf，2016，25（3）：147-152. DOI：10.1136/bmjqs-2015-005076.
[25]	DEHAVEN M J. Multimorbidity，chronic disease，and community health science[J]. J Eval Clin Pract，2017，23（1）：219-221. DOI：10.1111/jep.12632.
[26]	MANNUCCI P M，NOBILI A，INVESTIGATORS R E P O I I. Multimorbidity and polypharmacy in the elderly：lessons from REPOSI[J]. Intern Emerg Med，2014，9（7）：723-734. DOI：10.1007/s11739-014-1124-1.
[27]	ABOUEID S，BOURGEAULT I，GIROUX I. Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario，Canada-a qualitative study[J]. BMC Fam Pract，2018，19（1）：69. DOI：10.1186/s12875-018-0760-3.
[28]	ARNOLD M. Polypharmacy and older adults：a role for psychology and psychologists[J]. Prof Psychol，2008，39（3）：283-289. DOI：10.1037/0735-7028.39.3.283.
[29]	WYTSMA-FISHER K，MUSTATA S，COWAN T，et al. A physical activity intervention feasibility study for kidney inpatients：a basic research protocol[J]. Can J Kidney Health Dis，2021，8：2054358120987052. DOI：10.1177/2054358120987052.
[30]	GÖHNER A，BITZER E M，DREHER E，et al. Integrated care management for older people with chronic diseases in domesticity：evidence from Cochrane reviews[J]. Z Gerontol Geriatr，2021，54（1）：54-60. DOI：10.1007/s00391-020-01796-1.
[31]	MCCANN E. Building a community-academic partnership to improve health outcomes in an underserved community[J]. Public Health Nurs，2010，27（1）：32-40. DOI：10.1111/j.1525-1446.2009.00824.x.
[32]	SMITH S M，SOUBHI H，FORTIN M，et al. Managing patients with multimorbidity：systematic review of interventions in primary care and community settings[J]. BMJ，2012，345：e5205. DOI：10.1136/bmj.e5205.
[33]	MIKLAVCIC J J，FRASER K D，PLOEG J，et al. Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity：a pragmatic randomized controlled trial[J]. BMC Geriatr，2020，20（1）：174. DOI：10.1186/s12877-020-01557-0.
[34]	CARTER B L，BOSWORTH H B，GREEN B B. The hypertension team：the role of the pharmacist，nurse，and teamwork in hypertension therapy[J]. J Clin Hypertens，2012，14（1）：51-65. DOI：10.1111/j.1751-7176.2011.00542.x.
[35]	STRUIJS J N，DREWES H W，HEIJINK R，et al. How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework[J]. Health Policy，2015，119（4）：522-529. DOI：10.1016/j.healthpol.2014.12.003.
[36]	MACIEJEWSKI M L，BAYLISS E A. Approaches to comparative effectiveness research in multimorbid populations[J]. Med Care，2014，52（Suppl 3）：S23-30. DOI：10.1097/MLR.0000000000000060.
[37]	CHEN X J，YAN J，WANG J Y，et al. Chinese expert consensus on the application of comprehensive geriatric assessment for the elderly[J]. Aging Med （Milton），2018，1（2）：100-105. DOI：10.1002/agm2.12019.
[38]	NGANGUE P A，FORGUES C，NGUYEN T，et al. Patients，caregivers and health-care professionals' experience with an interdisciplinary intervention for people with multimorbidity in primary care：a qualitative study[J]. Health Expect，2020，23（2）：318-327. DOI：10.1111/hex.13035.
[39]	TADEU A C R，E SILVA CAETANO I R C，DE FIGUEIREDO I J，et al. Multimorbidity and consultation time：a systematic review[J]. BMC Fam Pract，2020，21（1）：152. DOI：10.1186/s12875-020-01219-5.
[40]	PIÑEIRO-FERNÁNDEZ J C，FERNÁNDEZ-RIAL Á，SUÁREZ-GIL R，et al. Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity[J]. Intern Emerg Med，2022，17（3）：789-797. DOI：10.1007/s11739-021-02876-9.
[41]	VAN DONGEN J J，VAN BOKHOVEN M A，DANIËLS R，et al. Developing interprofessional care plans in chronic care：a scoping review[J]. BMC Fam Pract，2016，17（1）：137. DOI：10.1186/s12875-016-0535-7.
[42]	VERMUNT N，ELWYN G，WESTERT G，et al. Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients：a framework analysis[J]. BMC Fam Pract，2019，20（1）：76. DOI：10.1186/s12875-019-0966-z.
[43]	穆晓敏.老年慢性病共病模式挖掘与防控策略研究[D].长春：吉林大学，2021.
[44]	GREMBOWSKI D，SCHAEFER J，JOHNSON K E，et al. A conceptual model of the role of complexity in the care of patients with multiple chronic conditions[J]. Med Care，2014，52（Suppl 3）：S7-S14. DOI：10.1097/MLR.0000000000000045.
[45]	BUNKER J M，REDDEL H K，DENNIS S M，et al. A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams：study Protocol[J]. Implement Sci，2012，7：83. DOI：10.1186/1748-5908-7-83.
[46]	CHANG E T，ZULMAN D M，ASCH S M，et al. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration （VHA）：study protocol for the PACT Intensive Management （PIM） randomized quality improvement evaluation[J]. Contemp Clin Trials，2018，69：65-75. DOI：10.1016/j.cct.2018.04.008.
[47]	BODENHEIMER T，WAGNER E H，GRUMBACH K. Improving primary care for patients with chronic illness[J]. JAMA，2002，288（15）：1909. DOI：10.1001/jama.288.15.1909.
[48]	BARÉ M，HERRANZ S，ROSO-LLORACH A，et al. Multimorbidity patterns of chronic conditions and geriatric syndromes in older patients from the MoPIM multicentre cohort study[J]. BMJ Open，2021，11（11）：e049334. DOI：10.1136/bmjopen-2021-049334.
[49]	MORRIN L，BRITTEN J，DAVACHI S，et al. Alberta Healthy Living Program—a model for successful integration of chronic disease management services[J]. Can J Diabetes，2013，37（4）：254-259. DOI：10.1016/j.jcjd.2013.04.001.
[50]	CIMPEAN D，DRAKE R E. Treating co-morbid chronic medical conditions and anxiety/depression[J]. Epidemiol Psychiatr Sci，2011，20（2）：141-150. DOI：10.1017/s2045796011000345.
[51]	FISHER E B，CHAN J C N，NAN H R，et al. Co-occurrence of diabetes and depression：conceptual considerations for an emerging global health challenge[J]. J Affect Disord，2012，142 Suppl：S56-66. DOI：10.1016/S0165-0327(12)70009-5.
[52]	HALLI-TIERNEY A D，SCARBROUGH C，CARROLL D. Polypharmacy：evaluating risks and deprescribing[J]. Am Fam Physician，2019，100（1）：32-38.
[53]	LOEB D F，BAYLISS E A，CANDRIAN C，et al. Primary care providers' experiences caring for complex patients in primary care：a qualitative study[J]. BMC Fam Pract，2016，17：34. DOI：10.1186/s12875-016-0433-z.
[54]	KASTNER M，HAYDEN L，WONG G，et al. Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity：a realist review[J]. BMJ Open，2019，9（4）：e025009. DOI：10.1136/bmjopen-2018-025009.
[55]	BRAILLARD O，SLAMA-CHAUDHRY A，JOLY C，et al. The impact of chronic disease management on primary care doctors in Switzerland：a qualitative study[J]. BMC Fam Pract，2018，19（1）：159. DOI：10.1186/s12875-018-0833-3.
[56]	TSILIGIANNI I，GOODRIDGE D，MARCINIUK D，et al. Four patients with a history of acute exacerbations of COPD：implementing the CHEST/Canadian Thoracic Society guidelines for preventing exacerbations[J]. NPJ Prim Care Respir Med，2015，25：15023. DOI：10.1038/npjpcrm.2015.23.
[57]	RIJKEN M，BEKKEMA N，BOECKXSTAENS P，et al. Chronic Disease Management Programmes：an adequate response to patients' needs?[J]. Health Expect，2014，17（5）：608-621. DOI：10.1111/j.1369-7625.2012.00786.x.
[58]	O'TOOLE L，CONNOLLY D，BOLAND F，et al. Effect of the OPTIMAL programme on self-management of multimorbidity in primary care：a randomised controlled trial[J]. Br J Gen Pract，2021，71（705）：e303-311. DOI：10.3399/bjgp20X714185.
[59]	JAMIESON N J，HANSON C S，JOSEPHSON M A，et al. Motivations，challenges，and attitudes to self-management in kidney transplant recipients：a systematic review of qualitative studies[J]. Am J Kidney Dis，2016，67（3）：461-478. DOI：10.1053/j.ajkd.2015.07.030.
[60]	王书梅. 社区伤害预防和安全促进理论与实践[M].上海：复旦大学出版社，2010.
[61]	RUSTAD J K，MUSSELMAN D L，NEMEROFF C B. The relationship of depression and diabetes：pathophysiological and treatment implications[J]. Psychoneuroendocrinology，2011，36（9）：1276-1286. DOI：10.1016/j.psyneuen.2011.03.005.
[62]	FULTON T R，PENNEY B C，TAFT A. Exploring a chronic care model in a regional healthcare context[J]. Healthc Manage Forum，2001，14（2）：6-24. DOI：10.1016/S0840-4704(10)60801-0.
[63]	BAUER M S. The collaborative practice model for bipolar disorder：design and implementation in a multi-site randomized controlled trial[J]. Bipolar Disord，2001，3（5）：233-244. DOI：10.1034/j.1399-5618.2001.30502.x.
[64]	SOUBHI H，BAYLISS E A，FORTIN M，et al. Learning and caring in communities of practice：using relationships and collective learning to improve primary care for patients with multimorbidity[J]. Ann Fam Med，2010，8（2）：170-177. DOI：10.1370/afm.1056.
[65]	GOEHNER A，KRICHELDORFF C，BITZER E M. Trained volunteers to support chronically ill，multimorbid elderly between hospital and domesticity - a systematic review of one-on-one-intervention types，effects，and underlying training concepts[J]. BMC Geriatr，2019，19（1）：126. DOI：10.1186/s12877-019-1130-2.
[66]	ROSATI S，ZEMA M，CASTAGNERI C，et al. Modelling and analysis of four telemedicine Italian experiences[J]. Annu Int Conf IEEE Eng Med Biol Soc，2017，2017：2634-2637. DOI：10.1109/EMBC.2017.8037398.
[67]	BERWICK D M，NOLAN T W，WHITTINGTON J. The triple aim：care，health，and cost[J]. Health Aff （Millwood），2008，27（3）：759-769. DOI：10.1377/hlthaff.27.3.759.
[68]	BYRNE J，XU G，CARR S. Developing an intervention to prevent acute kidney injury：using the Plan，Do，Study，Act （PDSA） service improvement approach[J]. J Ren Care，2015，41（1）：3-8. DOI：10.1111/jorc.12090.
[69]	YANG Z H，MA X B，CHEN Y，et al. Effects of a quality improvement program to reduce central venous catheter-related infections in hemodialysis patients[J]. Am J Med Sci，2021，361（4）：461-468. DOI：10.1016/j.amjms.2020.10.018.
[70]	GARG T，ANZUONI K，LANDYN V，et al. The AGING Initiative experience：a call for sustained support for team science networks[J]. Health Res Policy Syst，2018，16（1）：41. DOI：10.1186/s12961-018-0324-y.
[71]	NG C J，LEE Y K，ABDULLAH A，et al. Shared decision making：a dual-layer model to tackling multimorbidity in primary care[J]. J Eval Clin Pract，2019，25（6）：1074-1079. DOI：10.1111/jep.13163.
[72]	KASTNER M，MAKARSKI J，HAYDEN L，et al. Effectiveness of an eHealth self-management tool for older adults with multimorbidity （KeepWell）：protocol for a hybrid effectiveness-implementation randomised controlled trial[J]. BMJ Open，2021，11（2）：e048350. DOI：10.1136/bmjopen-2020-048350.