出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Disease management programs are a component of the coordinated care project Primary Health Care PLUS (PHC PLUS) in Poland, co-financed from the European Social Fund under the Operational Program Knowledge Education Development, financed under the European Commission Priority Axis 4 and 5. Together with health check-ups, coordinators of care and patient education it constitutes a set of systemic solutions aimed at creating a coordinated care system. Description of policy context and objective : The essence of the disease management program is that health care providers offer active care for chronically ill patients. Disease management process starts with the diagnosis that is followed by in-depth diagnostics, and results in individual medical care plan preparation with the active patient’s involvement. It includes therapeutic measures aimed at treating the disease or minimizing its effects. Services financed under the disease management program include diagnostics and treatment of patients with selected diseases by a primary care physician in collaboration with specialists in diabetes, endocrinology, cardiology, neurology, pulmonology, rehabilitation and with physiotherapist. Targeted population : PHC PLUS pilot project is targeted at adult patients diagnosed with or suspected of at least one of 11 chronic diseases: type II diabetes, spontaneous hypertension, chronic coronary heart disease, chronic heart failure, persistent atrial fibrillation, bronchial asthma, COPD, hypothyroidism, parenchymal or nodular goiter, osteoarthritis of the peripheral joints and spinal pain syndrome. The stage of disease should allow treatment in primary health care. The disease management programs started on 1st July 2018 in 41 medical entities. Now, 1412 patients have agreed to participate in the cardiology program, 809 are treated in the rheumatology/neurology field, 440 in endocrinology, 370 are diabetic patients and only 149 use the pulmonology program. There were 16 refusals to participate in the disease management programs although the diagnosis has been made. Many patients are still in the process of classification, which gives a chance to increase theirs number soon. Transferability : Implementation of such a program can bring particularly great benefits in countries that do not allocate large amounts of money to health care. The implementation of the program in Poland will also result in the characterization of the model operating process and characteristics of pathways. The solutions developed can be used as a starting point for other countries willing to implement the disease management programs. Conclusions : The implementation of the disease management program increases the competence of the primary care physicians. They manage the budget entrusted, under which they can commission for example rehabilitation, which causes a significant acceleration of the healing process. In addition, the PHC physicians obtain access to: telemedicine, specialist consultations; a wider range and the number of preventive and educational activities; a wider range of diagnostic and physiotherapeutic services; and consulting with other outpatient care specialists. Thanks to the implementation of the PHC PLUS project patients can have a chance to actively participate in decision taking. This is an important step towards patient empowerment.
关键词：poland ; disease management programs ; phc plus project
