Integrated Care for Chronic Conditions: A Multi-method Controlled Evaluation, 2011

The Central Norway Regional Health Authority (Helse Midt-Norge RHF) is to develop a structured collaboration between community and specialist care for people with chronic conditions. As an important part of this the patients will be mobilised by training and education to become more independent and self-reliant. The new integrated care will be based on the ordinary healthcare systems in the municipalities (coordination unit, general practitioner, home based care and nursing homes). The main contribution from the specialist health care is transfer of competence, tutoring and to operationalize evidenced based medical guidelines into local clinical pathways. Individual care plans will be used when suitable for the purpose. Monitoring and electronic communication will be facilitated by establishing a call centre. The central will be a useful tool to coordinate specified actions to the patients, in cooperation with the health care services, patients, their relatives and organizations. The main purpose of this protocol is to design a research based evaluation of the project, using both quantitative and qualitative methods. Indicators of admissions and re-admissions at general hospital, use of nursing homes and home care support, and patients level of function and quality of life will be important quantitative measures. The qualitative study will evaluate the patients and their relatives satisfaction on the integrated care model, organisational effects and the communication and collaboration between the different levels in the health care services. This is the first time a model with a call centre especially designed for the care of chronic patients is tried out and evaluated in Norway. If the integrated care model shows a significant positive effect, the model should be incorporated as an alternative to the acute care model for patients with defined types of chronic conditions.

挪威中部地区卫生管理局（Helse Midt-Norge RHF）将构建针对慢性病（chronic conditions）患者的社区医疗与专科医疗结构化协作体系。作为该体系的核心环节之一，项目将通过培训与教育赋能患者，提升其自主独立性与自理能力。新型整合式医疗服务（integrated care）将以各市的常规医疗系统为依托，涵盖协调单元、全科医师、居家照护及养老机构。专科医疗的核心贡献在于输出专业能力、开展临床指导，并将循证医学指南转化为本地临床路径。在适配场景下，将采用个性化照护计划。通过设立呼叫中心（call centre），可为患者监测与电子沟通提供便利。该中心将作为实用工具，协同医疗服务机构、患者及其家属与相关社会组织，协调针对患者的专项医疗行动。本研究方案的核心目标是设计一套基于研究的项目评估体系，采用定量与定性研究相结合的方法。定量评估指标将包括综合医院的入院与再入院率、养老院与居家照护服务的使用情况，以及患者的功能水平与生活质量。定性研究则将评估患者及其家属对整合式医疗服务模式的满意度、组织效能，以及医疗服务体系内不同层级间的沟通与协作成效。这是挪威首次针对专为慢性病患者照护设计的呼叫中心模式开展试点与评估。若该整合式医疗服务模式展现出显著的积极效果，将可作为特定类型慢性病患者急性照护模式的替代方案予以推广应用。