ก ก ก ˘ - mahidol university€¦ · # ˇ กก#3 180 ) ˘# ก - $ ˘ˇ & 2 3 2030...
TRANSCRIPT
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������������ �����ก����������ก��ก������
�����.���� �������� �. (ก���� ���
ก��������)
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������ก������� ��������• ก����������������������ก��������ก ��ก�������!• "��#��"�$� ��%$&��'����!(����)��� *+• ��"�,ก���-.�������/0����• � ก������������-.�������/0����-�ก��,���'"" ������"# �����(1���• "��#����ก��ก��,�� • ����� �������ก��,�� ������#�������/0����!�%--'��• ������ก��,�� ������#�������/0���� -�ก CCM model, ICCC model,
Transitional care and case management• ������������� � ���1�1������� !ก��,�� �����,1��������#�����
��/0����-�ก��,���'"" �������
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ก����������� � �!�� ��" #$�% �&��'���������� ���(ก)��*� +�,���!�
+�-.��� ��������� ��(�, hyperuricemia , anemia (hematocrit 16) , ���ก�?��+�-. ���)���+���+��-@��?�!����������ก���-� ��!������ A)?� �B ���ก���"C'����.)"�)� �������.��@�!� A�?+�-��"ก
D������E �(ก��!'?��(F� ก���-�+�-@��?������+�,�+�-@�
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ก����������� )��!�� ��" D# �% +�,�+���������A��� C���� !����������� � �!�� ��" #$�% +�,�+������ *�%ก���� myelitis!�?���I )����
+� �!��!�? JKก+� � �����.L� �MNN"���กกL����ก���?��ก��+� �+�O�� )��!�� ��" PQ �% +�,� ischemic stroke ��กS�A���������� Q*
��� +C?����ก����กS�T.L��ก * ��.�A�+��� Q, * ������E �?��� ���+���� +�Oก� � ��" QQ C�� ���&��%��@U +�,�+������ �?�V�� �T"� �
self monitoring �?�+���������-F��-@�Y� )��!��+)-.���N��ZZ�% �&������(� �(ก)��#� �����������
�?��+�,�J%��@C�����C?��C����*��� ����������� U[��� !���� �?��L� HD �?��(��&���(F�^(?�(���"
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� ����ก������� ������������������� (massive increase- ก�����, ���� !��)
� �#��$%��&��'����(�(�$��)���)�*��ก��+,- ���.�(access) �������'��)�*��/+)
� �ก�!��������0� ���#� ก �������0������1!�� .��$��ก���2��ก������������- �� )ก��+,- ��3��$���$��
� ���0� #�� �#�$- � �+ ��+ �����+ - ����4� ��3�('#�������#� ก 35 )����/�8 (WHO, 2008a)
�#��.%���������� �.��!������������
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� ��� ������������&�!��� ��ก��������'��'���/+)��%�- ����ก �� (80% ��������) - �9,)+)����ก�.- ���$�
� �����������2��ก��/+) $�+ก����3���'���.��:�!������-�3����-�ก ����� )9,)�;#��'��1!��('#���'�+'
� ���������� - � HIV/AIDS ����$%��#�9,)�;#��������� �#��$%��&��3�+3#�������0� ����ก���� ��ก!��.3#����(��(��'�$��)����� ��ก*��ก�������������������������.��!��- �.��!�#�
(�3�)�#��.%���������� �.��!������������
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• Chronic illness• Chronic conditions• Long term conditions• Lifestyle diseases• Non communicable disease (NCD)
�%�$%�ก�+�#���������������
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���������� (Chronic disease)=����'��&�����# ����- �ก)�# �)���3��()�>?
(WHO,2002)
!�#�������� : ��� �.��!���'��)��ก��ก��$�+ก���3��������#����&��8 ���.�0>�8 (WHO,2002)
NCD ����'�/�3��+(���-�3ก�+$�ก���:�ก��� #�*'('#�� - �.���-#+ )��
(WHO,2002)
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� ���0� #�� 180 )�����#� ก� ��� �#�$- � �+ ��+ .� ��ก������ ������4� .� ��ก����� (��+, ก�������ก��, ��0, %�/.)� �3, �)���
� ������+�� ���$ �#����ก�C�����
���+������ �
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� WHO ��+#3��'���&�0� #����กก#3� 180 )�������#� ก- �$������&� 2 �3����8 2030
� ก�����$�ก0� #�� 1.1 )�����8 2005� ก��0 80% ���9,)�&�0� #���'�.'�('#��ก�+���������/+)��%�- ����ก ��
� ก��0����� �������9,).'�('#��ก�+ก3������ 70�8, 55% �&�9,) ���
� ���'ก 10 �8�)�� �)� ก��.'�('#������������กก#3� 50%WHO 2009a �)���� ICN 2003
�)��, ก'��#ก�00� #��
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� �&�.� ��ก��������+�0 ����� �����1 17.1 )��.'�('#�����8 2004 H����&� 29% ���ก��.'�('#��
���#� ก H��� 7.2 )��ก�+$�ก��� �+ ��+�������'- � 5.7 )��$�กstroke
� ก��.'�('#��ก�+���������/+)��%�- ����ก �� 82% �(��- � ����3�>ก��
� ���8 2030 $�.'�('#��$�ก CVDs 23.6 )���� $�ก��� �#�$- �stroke - �������&�.� ��ก��������+�0-�ก-�+�����'��- �SEA
��� �#�$- � �+ ��+ (CVDs) WHO 2009
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� �&�.� ��ก��������#� ก 7.4 )�������8 2004 (13%) ���ก��.'�('#������ �+
� ��+, ก������� ��, ��0, %�/.)� �3- ��)����&�.� ��ก�����
� � ���- �(��-�ก�3��ก��� ��กก#3� 30% ���ก��.'�('#���2��ก��/+)
�)��, ก'��#ก�0���4� (WHO 2009c)
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� ก��.,00� �'��&���$$��.'���.%�����'�.�+� ���4�ก�+$�กก��� '���-� ����H C H���ก�+$�ก.� ��!����ก- ����:�ก���
� .� ��ก��.'�('#��$�ก���4�$����������3�/� ���8 2030 ��+#3� 12 )����
(�3�)�)��, ก'��#ก�0���4� (WHO 2009c)
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� ก����ก�C�����$�ก������+�� ���$�������� ��$$�0���'�� 300 )���&���� �+� �����1 210 )���&� COAD ��ก$�ก�����' allergic
rhinitis - ���������������
������+�� ���$������� (WHO2009d)
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� �#��$40�;#������)�/���('#�� � �+������Q��ก������-�3+4ก #����3� 9,)� �3 #��ก ���� 9,).,�����
� �3��()$3��.,���������+�00��� .���� - ��RSก�$� ��+�#��0��� - �(��(��'�$�0�� �*���ก�!��- �# ��������
� .,�.'�# ���0)��, ก���กR� - �ก���%����� 9 ก���0�3����0���# !���ก��+,- 9(��/���0��# -03����ก���%� $�+��00����� ).�+� ( �3#� 4ก�'�.�+)
9 ก���0$�ก�#��$40�;#��������
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� ��1!��('#�� + �� ������+�0�#����ก$����0��� - ����0���#� 9 9 �� + �...(��:��ก�$ - ��RSก�$(���� �3��()$3�����0��� �����00.��!������#���$T�� +,- ��กR�
� �3��()$3������ก���2��ก��!�#�-��กH)��$�ก����������
(�3�)9 ก���0$�ก�#��$40�;#��������
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� ���/+)- �.*������.����� ก���กR�- �ก���,) ���.��� �����3��.��0.������.����� .!�#�ก���%����- �ก��$)������ .���-#+ )�����.����� ก���U�0���ก��+,- .��!��.3#�0��� - ���กR�9(���#����'�+
� ���:�ก��� .��!��+4ก � #�Q�:���
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� �#������:�����.�����%�� )�'9 �3�('#��- ��#������ ก�� ����ก'��#ก�0����.�)��� !��- �.����%��#��#��.�+#ก
� ��+�0�#����ก$�ก�0!�#��#���&���,3-�)�-�)� �&�9 �3��#��.��!�����.��!��
��$���(�0��#���������������
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� ��$$��.'��� �ก�'����0/+) (modifiable risk factors)� .,00� �'�� �� ��- ��!(��ก���'�/�3+'�3�.��!��� ��+ก����กก%� ��ก��� +���-� ก�V� C��ก� .%�.3������� �#����'�+
��$$��.'���: �#��(�ก���!�#�$40�;#��������
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� ��$$��.'�����+�0ก ��� �#��+��� ��.,�� ��%��� .,������ /������ ��+ - �� �#���)#�
(�3�)��$$��.'���: �#��(�ก���!�#�$40�;#��������
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Self –Care Philosophy
Patient/Family Philosophy
QOL Holism
Maximize Potential (Optimized)
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Self care
• ก��ก������������������ �!�"��� �$ %���ก&�'��()%�* �+� ,-./�$���,��,�+/�$ (Orem,2001)
• ����,����0�1ก�������1������ก�����ก+�ก���� %����21�$ %������ ,-./�$ ��ก&�,-./�$ "� �,�����,�+�,-./�$�"�����3�ก�/�$
• ก�������1���21��������1 %����กก��$)%��1���'��,����45�1ก�����ก��/���,-./�$0)�ก��$)%�$�����,-./�$
• ก������� %����21�� %�� ������ %����1.��,-./�$ ก������� %����21�������$�61�ก�����ก������� %����217����%�'(orem 2001)
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Self care
• A broad concept, referring to individual responsibilities for healthy lifestyle behaviors required for human development and functioning, as well as those activities required to manage acute and chronic health-care conditions.(Richard et al 2011)
• Self care agency and dependent care agency• Chronic illness self care �ก+�.)�1/���1��� �.���.��
������������$ %�1 ��������1������,���ก/.��.���(Becker,1998)
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Self Management
• An ability and process that individuals use in conscious attempts to gain control of his or her disease, rather than being control by it(Thorn,2003)
• Chronic disease self management programs..to facilitate patients’abilities to self monitor-symptom,make informed decisions as active partners in the management of their health(Chodosh et al.,2005)
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����������ก����������� !"�#$����
�������%��&�'('ก (Clinical outcomes)
����������ก��%3�4(��%56 (Functional outcomes) %56�8ก89��ก�:;� <"=>:�� !"?5!:���(
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����������ก����������� !"�#$����
@A9"�5!��89ก������8��8�!
�898���&3�(B�CB�&DE;��F5 '8 eof prime importance in achieving treatment goalsf
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'F�F5�MD�;�� : �NO4�
ก��F9 !"4�#������ !�!9��@� P4�A5&DE;��F5 '84�#����:��D�&DE;��F5 '8P4��5�B$( “health
related QOL”
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The vision of the 21st century health care system
• Investing the health care• Patient centered health care
• Consumer driven health care• Provider friendly health care
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Chronic care management
• Chronic care model• Innovative care for chronic conditions
• Transitional care• Case management
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2554 31Wagner, et al, 1999
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Chronic Care Model (CCM)Good chronic illness care
Primary care setting
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��&���<ก�:�������::ก����������� !"�#$���� (CCM)
Community resource and policiesHealth system organization of health careSelf management supportDelivery system designDecision supportClinical information system
Wagner, 1999
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Community, Resource and Policies
ก��PF���<(3��4�9���<Z!F(�P(FDAF(A�PF�
"�#6�8�:M(��& �A8���ก���������� !
ก��ก�<8D�(P4�A5M9 (�9 AP(Z���ก�A���FDAF(
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Organization of Health Care
M���� �[(���A��&�ก�, =���<:: ��<ก�@ก%56M9�"M�'AP4�"ก'�& �A����;�!��<A5&DE;��M��
M9�"M�'AP4�"ก'��<::ก�������:::��E�ก��
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Self Management Support"M�'A������<"8�5!A����� !P(ก��=��ก������MD�;��
PF�ก� '�5%56A5��<M'%�';��"�#6�M(�:M(D(ก��=��ก������8("��
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Self Management Support
• ก��� %��*�*1� ,��1�����1ก������,-./�$�1��� � �!�"����$ %�*����"�����,����0�1ก�����ก���1����ก+������ % �$ %�ก��!��ก�1�������/����� ��������������1 %��
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Design of Delivery System"F#6�A�6( 9��<:: effective, efficiency clinical care
M(�:M(D(ก��=��ก������8("��
ก3�4(�:%:�%�<4 9��%5AMD�;�� :%:�%���%5A
%5A%56A5��<M'%�';��
��&���<ก�:���%5A nurse case manager, medical specialist �MA. ^�^
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Decision supportM9�"M�'Aก������%56��_�!4��ก`�(�����'�
& �AMA�&�P= & �AF�:�������� !
ก��PF��( �a':�8'%��&�'('ก%56��_�!4��ก`�(�����'� (guideline, protocol)
"�b(M9 (4(B6����ก���a':�8'%��&�'('ก��<=3� �(
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Clinical Information Systems=���<::���A���������� !��<ก�D9A��<F�ก�
=��%3�%<":5!(����� !
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:%:�%���%5A��������� !"�#$����
%5A��������� ! 4A�!CB�ก�D9A:D&��ก�%56A5ก��8'�89�M#6�M��ก�(�!9��MA63�"MA�"ก56! ก�:ก������ก�D9A����� !��<A5M9 (�9 AP(ก������
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ecomplementary functionsf
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%5A��������� !"�#$����%56A5��<M'%�';��
P(MC�:�(%56�a':�8'��(
(�กMC�:�(%56�a':�8'��(
Multiple practice-primary and specialist care
General practice and community agency
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2554 47
%5A����%56A5��<M'%�';��
A5ก���:9�& �A��:�'�F�:%56�(9P= 9�=<@����::�'ก��%��&�'('ก��<M(�:M(D(ก��=��ก������8("��
ก��A5M9 (�9 A���M��� 'F�F5�-nursing care management, clinical pharmacy
Z���ก�Aก������%56A5��<M'%�';��A�ก=<8���AD9�A�6(��<PF�%�กf<%564��ก4��!���%5A
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%5A����%56A5��<M'%�';��ก������ก3�4(���<F�ก�ก�D9A"�\�4A�! "�'6A=�กA5�( �a':�8' protocol
ก�� ����(ก����กf� (treatment planning) ����� !�89�<&(
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ก����Bกf�%56A5��<M'%�';�� (ก����Bกf�"�b(ก�D9A)
ก��8'�8�A/ก��(�� "�#6�&�(�:�NO4�...�#6(d �� ! '�5ก��89��d (� A%�$�Z%�_��%�)
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��&���<ก�:���%5A��������� !"�#$����
�!�:�����=��ก����!ก�E5 (nurse case manager)
��%!����"F56! F�O
";M�Fก�&�'('ก
�MA.
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��<"�>(M3�&�O��<M'%�';��ก����������� !"�#$����8�����_�!%5AM4M��� 'F�
%5A����%56��<M:��M3�"�>= A�กA5�!�:����<";M�Fก�%56A5%�กf<%��&�'('ก��<���(�h8'ก��A
��&���<ก�:&#�ก��=��ก��ก�D9A��<F�ก� �( �a':�8' protocol ก��M(�:M(D( ก��=��ก��8("����<8'�8�A89�"(#6��
ก��A5M9 (�9 A�����%!����"F56! F�OP(ก��P4�ก����Bกf���<P4�& �A���"�#6�ก��M9�89�=<F9 !P4���������5�B$(
Wagner,2000
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�!�:��ก�:ก����������� !"�#$����
Bodenheimer, et al (2005)
� Nurses as leaders in chronic care
� To champion transformation of chronic care
� By nature of education and role
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�Eก���������ก� +���ก�?�A�?��ก����������������-�������'��������� Y (inter-sectoral collaboration)
� ก��+�,�กa���� Ottawa
� ก��+���@��F����?��������กก���N��"��+���������� ̂�)�C��"�+�����.�
� �"C'����^�N�ก���� +��Sdก N F����e�B��� Tf@�+�,��(���ก��F����������������-
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(��) �Eก���������ก
� ก����?��+�� ��"C'�� (population health approach)
� �� ก���"C'����@��"�'��N��?�!�?���ก��������"����������F�����Fก��C�)"�)�
WHO (1986)
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���Fก����?��+�� ��"C'��)"�)�
� �������N�ก�����ANF�����+�-�A� (̂?)�� ���� 68%� �������N�ก�����+�-����AN������� ���� 73%� ��A)?N���A�ก����กS������AN����� ���Fก��ก��A�?����(?�?������F���')��ก�� ()��F���m�ก��ก��+ก ���+�-.���)
Barr, et al 2003
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The Expanded Chronic Care Model (Expanded CCM)
� �(���ก��ก����?��+�� ��"C'�����)�ก�+C?�!�A�ก���m�ก��F��N��ก����+�-.���� C��� CCM A�?ก�?��ก!�+�-@��'�����+�-.��� !��NL�ก��+V����+NO��w��� ������"����)�)�F��)"�)��(�ก�����"C'����� �"����.�ก���m�ก��F��N��ก����+�-.���� ������"������C�������ก�����"C'����C��"� )"�)� F�����)�ก�
(Barr, et al 2003)
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��&�ก���(�A�!Z�ก
ก�:ก����������� !"�#$����
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��������� : ��� ����������ก����� ���
• ��� ���!�ก����" �������"��� ���(empower)
• ��� ���!�ก�!����#�$ก�� ����������ก�� ��� ��� (interaction)
(WHO, 2002)
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�����ก�" : ���%&"&"��ก���%�'�� ��(&%$�ก��)��)�
• ��� ���!�ก��������ก���'��*������ �(+&��"� )�"��ก� �"'��'�� ,&"ก��
• ����ก�%� ��(-&"�(&'��.�$�/���)*��ก�
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(1$&)�����ก�" : ���%&"&"��ก���%�'�� ��(&%$�ก��)��)�
• ก� ����1�.�$&��$���(+�3�%&"ก�!)����ก3�4/- )(-&5(&.��• %�ก�!������*���ก��ก� ,&"ก��• .�$�/����3�%�&���• .�$�/ ��(&%$� )(-&�6�"ก��'��$" ��6�)��!�)��)�
(WHO, 2002)
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�������� : ���������6���
• %�ก�&&ก����)�����1� ก/-��ก����#�• �6�����%�'��ก��"'��������• ��3.�$.���"4��&�$")�7��• ����ก� "��'�ก�$��
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(1$&)�������� : ���������6���
• ก�!��'�"��"!�'ก$���!�����ก��/��&�• �1�3�'��ก� 8,1��1�.�$ �/�"�&• %�ก����ก�9:ก;1$& �(-&"• �&"%��ก����" ��(&%$�
(WHO, 2002)
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(WHO, 2002)
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� -�#��+ก��+,- 9,)�;#��������� ���0� (/�3�(3-���C)�&�0�� �ก� �ก��ก���%� CCM /��()- ��&�0�� �ก�.%�������'� (Bischoff et al.,2009)
� ก��#��-9�ก��+,- ก��.���.��ก�09,)�;#� �U�.�����:C(��กก#3�-���C)
� ���0� �#�$�/+)��0ก����'��/WXก�0��ก'��#ก�0ก��+,- 9,)�;#���������&��#���)����
ก�����0� 9,)�;#��������ก��+,- 9,)�;#�������� : �����)�������ก�����0�
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� �กS��(�����$�กRC$�กก���กR�#�$��� ���0�������-ก��ก���กR�������0.����#���)��ก��+)��.��!���'�� '���-� �
� ก���() �กก������,�-00ก��+,- 9,)�;#�������� �.,3ก���U�0������� ���ก
ก��+,- 9,)�;#�������� : �����)�������ก�����0�
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� 9,)�;#���������&����(�ก��'��'�#��-�ก�3�� (3� ��� �#�$ ���4� 0� #�� �����+������� .��!��$�� - �����>
� 9,)�;#���������'�#�� ������� /�3 ����+�)��ก��ก����กR�� �+('#�� �)����+��� �)����Q����กR�ก��$�+ก������
� 'ก '���ก��ก%���0���ก��$40�;#�� ��1!��('#��- �9 ��:C���� ���ก
(WHO, 2002)
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� -�#��+ �ก���ก�����0� � ก��+,- ����� ก��+,- .��!�����C�#�� ก���'.3#��3#���ก����+.���$� ก��+,- �'���3�9,)�;#�- ����0���#�&�,��Cก ��� ก��#��-9��3#�ก�09,)�;#� : �YRZ'ก��0�� ��2� ���������� ก��+,- �3������
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� ��0��ก���U�0���ก�����0� ����.,�� .���*�����ก���U�0���ก�����0� ����.,�
ก����Q��ก���U�0���ก�����0� ����.,�
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� ก��+,- �+���3����(�ก�� ���(�ก�ก �3��2� ���� �'ก��#��-9�- �� )ก��+,- � (�����������1!��.%� ��0��ก��� ����$�กก��ก%� �+-9� -�#�U�0���� -03����ก�0.��(�ก���'�
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� ก��#��-9�ก����กR�- .%� ��0-�3 �0��� - (3#���ก��$�+��0'�0ก���%��������'�
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� .��0.���ก��$�+ก������� �#���,)- ���กR�� -��$,��$- ��#��(�������� ก��� )�%����กR���ก�����0� '����Y��ก���
(�3�)�'�ก��+,- �'��'���.��:�9
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� ก���&��'����กR���3���'���.��:�!��� ก�����กR��&�ก �3�� ก��+,- �+��'�
� ก����+����3������
Wagner, 2000
(�3�)�'�ก��+,- �'��'���.��:�9
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� �����YRZ' social learning� �����YRZ' self-regulation1) ��กR�ก��$�+ก���#��$40�;#��&�ก���'���,)- �
�Y��ก����'�('��%����� (self-directed)2) ก���'-��$,��$- �(���������������ก��$�+ก���#��
$40�;#��&���#ก%� �+ก��ก���%�ก��+,- ����
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3) .���-#+ )�����.���� ���0���# �'��%���� - ���000��ก��.��!����$.��0.��� �����$��+�#��ก��$�+ก������
4) ก��W2���+���- �ก����0.����3�ก��� '���-� ����!�#���� ��ก�� ����1C - �ก���%� �)��'��%�� )�'ก�����0��#�3�!�#�$40�;#�
Korff et al, 1997
(�3�)ก��$�+ก���'��&�ก�����.���#���3#����
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� ก��ก%� �+�2� ����3#�ก��� ��3��'���� �T���ก%� �+�2� ���- �ก��#��-9�� ก��.�)��-9�ก��WXก��กR� ก��$�+ก������- �0��ก��
.��0.�����3���3������� ก����+�����3���3������
Korff et al, 1997
ก��$�+ก���'��&�ก�����.���#���3#����(Collaborative management)
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� ก���U�0����'��'��1!�� ��)��3��()$3�� - ��&�/�/+)� ก��+,- -000,�1�ก�� �'�#�� ���.� �)�*�� $3��
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� ก���'.3#��3#���ก�����0����0��ก���'����(�(�.����*�)�*��- ��'���.��:�!��
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� ��� ��ก*���#��.%����- �$�+ก��+,- �+��() �กS��(�����$�กRC ก����)�ก�$ก�������ก���2��ก��- ���กR�.��!��
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ก��$�+ก��!�#�$40�;#�������� ���0� �'0�0��.%����- �
�'�#���&�9,)�%�
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ICNand
Its partnersand
Committed to preventingand
Better managing chronic diseaseand
Will work to promote a healthier world
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(Frolich, 2008)
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� ก�����0� '���#�*'('#��� �)��0- ���+ก������ �.��!��- �.�)��#�:'ก��� ���0����+�0(�����ก���2��ก��- ��#0���� ก��0-�#��+ก���2��ก������������- 3�(���� .��!��ก�0.���-#+ )��- �.����
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