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Main arrow Archive of previous Issues arrow ╣3 2015 (43) arrow PRINCIPLES OF ORGANIZING MEDICAL AND SOCIAL CARE DELIVERY BASED ON THE "LIFELONG FOLLOW-UP OF CHRONIC PATIENTS" MODEL (EXEMPLIFIED BY PATIENTS WITH PSORIASIS)
PRINCIPLES OF ORGANIZING MEDICAL AND SOCIAL CARE DELIVERY BASED ON THE "LIFELONG FOLLOW-UP OF CHRONIC PATIENTS" MODEL (EXEMPLIFIED BY PATIENTS WITH PSORIASIS) Print
Thursday, 09 July 2015

Starodubov V.I.¹, Mishina O. S.¹, Dvornikov A.S.²
¹ Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Moscow
² National Research Medical University named after N. I. Pirogov, Moscow

Contacts: Olesya S. Mishina, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Abstract. For decades foreign and domestic health systems have been looking for models of care delivery to chronic patients that would best correlate with the developed system of care organization to the population with due regard to the happening changes.

The purpose of this work was to develop a concept model of medical and social care organization to patients with chronic conditions. The "Lifelong Follow-up of Chronic Patients" model was substantiated on the basis of the identified specific features of care delivery to patients with psoriasis. We used the organizational design method to develop this model.

The main objective of model is to shift away from the widespread episodic assistance which is relevant in case of acute stages to the comprehensive long-term management of patients to maintain their health, working capacity, and decent quality of life.

The model is planned to be implemented at the Center for chronic diseases. To ensure a wide access to patients such Center is advisable to be set up as an organizational unit of an outpatient facility with relevant medical and rehabilitation and personnel capacities. Advantages of the Center for chronic diseases include the following: interdisciplinary approach, coordination and concentration of medical services in one place, creation of conditions for comprehensive preventive medical and social care, differentiation of volume and types of care depending on the risk of complications, maintenance of working capacity and decent quality of life.

Integration of the Center of chronic diseases with activities of the social support services and non-governmental organizations allows to increase medical and legal knowledge of patients, to develop self-management and peer support, to motivate patients to preserve health and follow a healthy lifestyle; to provide social and psychological assistance, to ensure medical and social follow-up during disease non-acute stages and to provide comprehensive rehabilitation.

Keywords. Patients with chronic diseases, care for chronic diseases, medical and social care.

 

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