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标题：Assessment of patient's and health professional's experience of integrated care: preliminary results from a pilot survey in Veneto Region-Italy
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作者：Silvia Netti Tiozzo ; Pietro Gallina ; Francesco Avossa 等
期刊名称：International Journal of Integrated Care
电子版ISSN：1568-4156
出版年度：2016
卷号：16
期号：6
DOI：10.5334/ijic.2970
出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Population ageing is associated with an increased co-prevalence of chronic diseases. For persons with multimorbidity, care fragmentation may lead to adverse outcomes and patient dissatisfaction while care management programs can improve quality of care. Veneto Region is conducting a pilot experience on integrated care involving persons with Congestive Heart Failure (CHF) and multimorbidity in a primary care setting. The purposes of the present pilot survey were to assess experience of integrated care among patients, general practitioners (GPs) and nurses involved in the project. Methods : Veneto Region Health-Care System is administered through 21 Local Health-Care Authorities (LHAs) which provide Government funded health care granting universal coverage with a per-capita financing system delivering preventive, primary and hospital care. In 2015, Veneto Region started an integrated care-program in the whole region, involving older persons with Congestive Heart Failure (CHF) and multimorbidity. 42 Nurses and 42 GPs received specific training on Care Management using a collaborative team—based approach. The eligibility criteria of patients' selection were “being registered with the participating GPs”, "age 65 years or older" and "with CHF". To target the patients with CHF, co-morbidities and complexity we used the case-finding tool of the Adjusted Clinical Groups (ACG) System that generates high risk case management lists. After obtaining informed consent, the care manager nurse assessed patient needs and preferences, created with GP an evidence-based Care Plan and an Action Plan for patient and care-giver. The nurse then starts a proactive monitoring phase by telephone, in person in the office, or at home. During this contacts, the nurse promotes and supports patients’ self-management, uses motivational interviewing to help patients manage their condition and provides ongoing education resources and general information. The Care Plan is regularly updated by the nurse and the GP and shared with the patient’s other providers to help coordinate complex care.
关键词：integrated care ; primary care ; pilot ; veneto region