标题：Update on Development of a national Framework and Implementation plan for Self management Support for Chronic conditions: COPD, Asthma, Diabetes and Cardiovascular disease
出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : An Irish national framework for self management support (SMS) for chronic conditions ( COPD, Asthma, Diabetes & Cardiovascular disease) has been developed over the last two years and implementation will start in 2017. The initial steps in the development of the framework were presented at the IFIC conference in Barcelona in 2016. Since then a national consultation was carried out on the draft framework, and further work done to incorporate the findings of consultation into the final framework, and to develop an implementation plan. This presentation will give an overview of the key findings from the national consultation; changes made to the framework; and outline the planned Implementation actions over the next 3 years. Description of policy context and objective : Ireland, like other developed countries, needs to re-orientate its health services, in light of its ageing population and chronic disease prevalence, in order to ensure the sustainability of health services into the future. While national guidelines recommend SMS for specific chronic conditions, this has not been implemented widely despite patient views that it should be a priority. Healthy Ireland: A Framework for Improved Health and Wellbeing 2013 – 2025 (DOH 2013) recognises the need to implement a model for the prevention and management of chronic illnesses, empowering people and communities, with an emphasis on partnership and cross-sectoral work to increase the proportion of people who are healthy at all stages of life. Arising from this, the HSE committed to finalising a framework and implementation plan for SMS for COPD, Asthma, Diabetes and Cardiovascular disease in 2016. Targeted population : People living with chronic conditions, initially COPD, Asthma, Diabetes and Cardiovascular conditions Highlights : the consultation on the draft framework gave rise to themes in relation to the content of the framework, communication issues, and implementation issues. Themes included: a high level of support for provision of SMS among patients, staff and HSE senior management the need for a ‘patient friendly’ version of the framework to help everyone to understand the concept of SMS and what should be provided Lack of resources in primary care were identified as a major barrier : this approach requires a high level of collaboration across the boundaries of primary care, community health organisations and hospital groups Implementation will require coordination at national and local level, training of healthcare professionals, information provision, communications plan, increased provision, access and standardisation of disease specific programmes; provision of peer and social support; a whole system approach Comments on transferability : While some areas have developed SMS services of varying types, there is inconsistent and fragmented provision - the national framework needs to guide development and coordination at national and local level. Conclusions : Main points from the consultation findings, the framework - a whole system model, and planned implementation actions over a 3 year period will be presented.
