出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In 2016, the SEMFyC and a multidisciplinary group of experts from all over Spain promoted a project based on the importance of the holistic management of T2DM patients.It became a relevant support to emphasise the "Diabetic patient management within the framework of the implementation of care strategies to chronicity" document. The main conclusion out of this document was that T2DM must be approached from an integral perspective with a clear focus on the patient, rather than a pathology-based management related to glycaemic control. Besides, all the stakeholders involved must be considered, taking into account their needs throughout the entire healthcare process. As a result, 23 key interventions grouped under 6 categories. Brief description of the practice change implemented : Going from managing the TM2D patient with a vision focused on the control of the glycated hemoglobin towards managing the patient based on their risk profile. Objective and theory of change : The Madrid Diabolution project pursues the implementation of this strategy through a prioritization of initiatives in which all care levels associated to the patient management are considered. Achieve a paradigm shift of the management of a chronic disease, which allows all stakeholders to be aware of the importance of carrying out health care focused on the patient's preferences Target : Diabetic patients. Patient community environment, including the health professionals involved. Timeline and structure : To develop the project at regional level, a multidisciplinary group of experts has been created, in which health managers, doctors, nurses, pharmacists and patients take part. The project has been structured in three major blocks: 1. Detection of opportunities: The group of experts through a focus group identified already implemented initiatives within the TD2M management, which could fit in the Diabolution framework. Moreover, non-related TD2M management initiatives were implemented too. Using the structure of the previous document, identify the most relevant and priority initiatives out of the 23. 2. Development of initiatives: Initiatives considered to have the greatest impact on patient based-management were prioritized. Besides, since these initiatives were aligned with Madrid’s Health System needs, they were easily adapted. The initiatives were validated by the group of experts following a Delphi methodology of two voting rounds. Thus, these initiatives were elected after being subsequently scored. With the result, 7 interventions have been prioritized: 1. Train nursing to enhance the patient's 2. Inform professionals of the resources available to them in the community 3. Train professionals in shared decision-making 4. Review and improve indicators 5. Create the integrated care process of the diabetic patient 6. Manage the patient with DM2 holistically 7. Incorporate in the evaluation the variables included in the processes Conclusions: When we start projects focused on the patient and not focused on the disease, a wide range of initiatives emerge, allowing us to increase the involvement of all the agents of the patient environment community, besides the self-care health. Lessons learned: Creating multidisciplinary projects involving all agents in the management of TD2M transforms the historically disease focused projects into enhancing patients’ experience projects.
关键词：integrated Care ; Diabetes ; Restructuring care ; patient experience
