出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Diabetes care faces enormous challenges due to the progressiveness and multiple manifestations and complications of the disease, which make necessary the coordination of numerous professionals from different settings around the diabetic patient. The current structure and functioning of diabetes care in many Spanish regions, mainly fragmented through primary care centers, departments of endocrinology and other hospital specialties, social care and a variety of support professionals is an obstacle to provide optimal care. The existence of new chronic care frameworks that have rendered better outcomes in other settings and the development of instruments to make them operational in our healthcare system is an opportunity to improve diabetes care. Description of practice change implemented : The program Advanced Diabetes Care Centers (ADCC) was developed to: a) improve integration between primary and hospital care; b) foster patient self-care management and c) establish personalized care plans. ADCC creates _virtual organizations_ with the professionals who provide diabetes care to patients within a defined geographic area. An ADCC is usually composed by primary care physicians and nurses of several primary care centers together with endocrinologists and specialty nurses of the department of endocrinology of their reference hospital and professionals that participate in diabetes care, such as ophthalmologists, pharmacists and others, all belonging to the same health area. ADCC program is supported by MSD having the commitment of the respective health area management. Starting in 2014, ADCC have been established progressively in several regions, existing now around 25 centers. The nature and scope of the specific improvement interventions introduced in each center are left at the decision of each multidisciplinary team after a thorough diagnosis of the baseline situation and a prioritization exercise. To make the baseline assessment, a 5 hour structured session using IEMAC-ARCHO Diabetes is held among the ADCC members. IEMAC- ARCHO (Assessment of Readiness for Chronicity of Health Care Organizations) www.iemac.org is an instrument developed to facilitate HC Organizations changes towards better care for chronic patients. Based on the Chronic Care Model, it also incorporates a population based, systemic (from health promotion to social care) approach with risk stratification and ICT use. IEMAC-ARCHO is a generic instrument suitable for all type of macro (policy and decision-making), meso (management) and micro (clinical) organizations in all type of settings and diseases, including multimorbidity. To perform ADCC assessment, both at baseline and after the implementation of improvements, IEMAC-ARCHO was adapted to a clinical setting and to diabetes. The resulting instrument, IEMAC-ARCHO Diabetes has 6 dimensions (corresponding to the 6 elements of CCM), 24 components and 50 interventions, with a rating scale from 0 to 100 divided into 5 segments, a glossary of terms and a webpage where to perform the assessment, www.iemac.org/diabetes. The purpose to develop a diabetes-specific instrument was to make it closer and familiar to practicing professionals. Key findings : Baseline ADCC assessment with IEMAC-ARCHO Diabetes gives overall ratings between the second and the third segment of the scale, which describe middle implementation but with evaluation only in its first steps. The dimension less developed in all ADCC is consistently Community Health, while Model of Care, Patient Self-Care Support and Clinical Decision Support are generally at the beginning of third segment (40 points). Ratings of the dimensions Information Systems and HC Organization are more variable, as they are more dependent on the centralized developments of each region. Assessment with IEMAC-ARCHO Diabetes also renders the identification of strengths and areas for improvement of the virtual ADCC in patient care. Improvement actions after assessments have been multiple and tailored to each ACDD, such as: establishment of clinical and assistance pathways between primary and specialty care, review of professional roles, expert patient programs, patient’s group training sessions, consulting endocrinologist, alarms in the information systems, etc. Highlights : The assessment exercise with IEMAC-ARCHO Diabetes by the multidisciplinary team of an ADCC renders outcomes of different nature. On one side, it allows to get: a) a rating of the baseline situation that will allow to measure progress in the future, b) orientation for improvement actions and plans and c) comparison with peer organizations. Being the above important, the process itself and the assessment session offers additional and important _soft_ benefits: some times, the session is the first personal meeting of different professionals that care for the same patients, they have the opportunity to discuss deeply about different aspects of patient care, listen to the different perspectives of the professionals of different settings (primary care, hospital, social care), knowing about specific resources available and, mainly, working together around patient needs without the fragmentation of their organizations. Conclusion : IEMAC-ARCHO Diabetes allows structured, thorough, joint discussion and analysis among the members of the multidisciplinary team that provide diabetes care to the same patients within a geographic area. It allows the identification of strengths and areas for improvement, facilitating the prioritization of actions and plans to improve care to diabetes patients by consensus reached by the team.
关键词：integrated diabetes care ; multidisciplinary team ; assessment tool ; assessment Process ; quality improvement
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