Chronic Disease Management- Implementation and Coordination of Health Care Systems for Depressed Elderly People, 2013

One of the greatest challenges faced by health care systems is the increasing burden of chronic diseases. Chronic disease management is a systematic approach to the coordination of health care interventions and communication at individual, organizational, regional and national level. Primary health care and community care are important settings for the prevention of mental health problems among elderly persons living in the community. An innovative approach to user involvement and evidenced-based care for depressed elderly persons was employed in this project. Phase 1 of the project was based on a qualitative approach, phase 2 consisted of implementation of the CCM in interdisciplinary teams working in mental health clinics and community health care; and phase 3 was to evaluate the outcomes of the implemented model as well as the patients' and family members' experiences of the care provided as well as those of the interdisciplinary teams. The research questions were: 1. What are the patient's subjective experiences of his/her mental health problems? 2. What are the patient's and family members' subjective experience of health care services? 3. How can chronic disease management for persons with depression be improved? 4. How can strategies to support patients' self-management of illness be improved? 5. What do the patients' pathways through the health care system look like? Five senior researchers and one postdoctoral student from four academic disciplines (public health, nursing, social science and education) collaborated in this research.

For further information about “Chronic Disease Management- Implementation and Coordination of Health Care Systems for Depressed Elderly People, 2013”, please contact the principal investigator.

医疗保健系统面临的最大挑战之一是慢性病负担日益加重。慢性病管理（Chronic Disease Management）是一种在个体、组织、区域及国家层面协调医疗干预与沟通的系统方法。初级卫生保健（Primary Health Care）与社区护理（Community Care）是预防社区老年人群心理健康问题的重要场域。本项目采用了一种创新方法，旨在促进抑郁老年人的用户参与及循证护理（evidenced-based care）。项目第一阶段基于定性方法（qualitative approach）；第二阶段包括在精神卫生诊所及社区卫生保健机构工作的跨学科团队（interdisciplinary teams）中实施CCM；第三阶段旨在评估已实施模型的效果，以及患者、家属对所获护理的体验，还有跨学科团队的相关体验。研究问题如下：1.患者对其心理健康问题的主观体验是什么？2.患者及家属对医疗保健服务的主观体验是什么？3.如何改进抑郁症患者的慢性病管理？4.如何改进支持患者自我疾病管理的策略？5.患者在医疗保健系统中的路径是怎样的？来自公共卫生、护理、社会科学及教育四个学科领域的五名资深研究员与一名博士后参与了本研究的协作。

如需了解有关《慢性病管理——2013年抑郁老年人医疗保健系统的实施与协调》的更多信息，请联系首席研究员（principal investigator）。