出版社：Utrecht University, Maastricht University, Groningen University
摘要：The experience of these 10 years of the Expert Patient Programme Catalonia (EPPC) has led us to being able to affirm that one of the key elements in the Integrated Care model, with a vision of future, it is the Person Centred Care. This element represents the walk to a paternalistic model of a deliberative model where the shared decision making among all the implicated agents, persons, families, caregivers and professionals it will be principal. It makes 10 years, in 2006, the Expert Patient Programme was born within the framework of a project of chronic pathologies management, in order to implicate the person in its welfare process. Objectives : - Share responsability to the person in the promotion of the selfcare - Improving the outcomes in healht of the person - Utilization of the healthcares in a more suitable way - Improving the quality of life and the personal satisfaction of the subjects Object population : Initially, the EPPC went adressed to persons with more prevailing chronic diseases at level of our population (Heart failure, COPD, diabetis type 2 ...). In the present, it has been extended with the vision of the person centred care, in other processes in the area of health promotion and prevention ( smoking cessation, obesity, caregivers...). Involved interested main ones : The EPPC promotes the active participation of all the implicated agents in its implementation as a nail factor of success (patients, expert patients, proffessional welfare patients, associations, families, community, local agents and managing) Outcomes and impact : RESULTS 2006 - June 2015 1st half Number of patients participating: 5206, Expert from which 340 have been Patients who have led in group. Coverage: 236 Primary Health Teams in Catalonia and 5 Hospital Joined within Catalonia and with the involvement of various Healthcare providers of the Catalan Health System. Diseases: Chronic Heart Failure, COPD, Diabetes Mellitus Oral type 2, Fibromyalgia, Anticoagulant Therapy, Breaking the tobacco habit, Anxiety, Chagas disease in its chronic stage,Breast Cancer Survivors, Depression and Obesity. Number of groups: 506. Professional Number of healthcare participating: Total number ace observers 902: 614 nurses, 234 family doctors and 54 social workers Impact : Improvement self-care Health problem / N / Start / Final/ 6months follow up / 12 months follow up - Heart failure / 338 / 25,65 (24,72-26,59) / 20,99 (20,14-21,84) / 21,85 (21,06-22,64) / 21,27(20,48-22,06) - COPD / 418/ 20,72 (19,91-21,52 )/ 17,02 (16,35-17,68)/ 17,04 (16,43-17,66)/ 16,96 (16,28-17,64) - Diabetis type 2_diet /4,62 /4,99 4,93 /4,84 - Diabetis type 2_exercice /4,41 /4,95/ 4,78/ 4,64 - Diabetis type 2blood glucose / 2,31 / 2,47 / 2,42 / 2,42 - Diabetis type 2-foot care / 3,01 / 4,07 / 4,12 / 4,14 Improvement health results Diabetis type 2 (N= 172 ) Start 6months follow up 12 months follow up HbA1c 7,35 7 7,05 CT 182,58 - 181,85 HDL 46,46 - 47,38 LDL 106,61 - 109,87 Reduce use of services 1 year before intervention (%) Health problem / N / Primary Care Team visits / Emergency visits /Hospital admissions - Heart failure / 338 / 39,18 / 43,75/ 50 - COPD / 418 / 26,09 / 14,29 / 14,29 Improvement Quality of life (X, CI95%, sd) Health problem / N / Start / Final / 6months follow up /12 months follow up - Heart failure / 338 / 30,6 (28,04-33,16 / 27,61 (25,21-30,01) / 27,18 (24,86-29,51) / 27,33 (25-29,65) - COPD / 418 / 4,93 (2,32) / 4,28 (1,57) / 4,13 (2,01) /4,24 (2,02) - Diabetis type 2 / 172 / 76,48 (73,95-79,01) / 76,38 (73,68-79,08) / 73,98 (71,27-76,68) / 71,90 (69,33-74,48) Satisfaction (X, sd) Health problem N Final ( x¯) Score (0-5 points) Heart failure 338 4,66 (0,60) COPD 418 4,62 (0,58) Diabetis type 2 172 4,68 (0,52) These 10 years of implementation of the Expert Patient Programme Catalonia has demonstrated us that this initiative favors the persons implication in tis welfare process, promotes the advance in strategies of person centred care on the part of organizations, favors the good use in the healtcare of utilization. The EPPC is recognized like some community assets and the person who exercises the paper of expert patient transforms into an agent of health. Conclusions : Given the outcomes obtained along these years in 2011, EPPC was recognized like one of the 32 strategic projects of the Health Plan 2011-2015 of the governmentof Catalonia and the year 2013 like one of the best practice at European level.
关键词：integrated care ; expert patient programme ; person centred care ; self-care ; community assets ; self-management ; chronic diseases
