出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background: Most current care models are disease- or symptom-focused and mostly do not account for the individual needs of patients with chronic diseases. The aim of this study was to develop an innovative, evidence-based and expert-based practice model for the management of patients with type 2 diabetes mellitus. Method: An iterative approach was used combining systematic literature search with qualitative methods, including a standardised survey of experts in chronic care (n = 92), an expert workshop of professionals (n = 22) and a multilingual online survey (n = 659). Using three consensus meetings involving researchers, policy makers and experts in chronic care, a limited number of core components and care recommendations was set up to develop a new chronic care model. Results: The developed ‘MANAGE CARE MODEL’ includes aspects of the health and social care system, resources derived from the living environment, aspects of health promotion and prevention, as well as an expanded understanding of improved outcomes as an integral part of chronic care. Conclusion: The MANAGE CARE MODEL provides guidance for the development and implementation of chronic care programs, regional networks and national strategies. Future research is needed to validate the model as an instrument of regional chronic care management.
关键词：chronic care; type 2 diabetes mellitus; prevention and health promotion; integrated care; chronic care model
