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首页> 外文期刊>International Journal of Integrated Care >Integrated Care Services for Chronic Disease – The Role a Programme Manager Plays in Making a Design a Reality
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Integrated Care Services for Chronic Disease – The Role a Programme Manager Plays in Making a Design a Reality

机译：慢性病综合护理服务–项目经理在使设计变为现实中所扮演的角色

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Introduction: Approximately 1 million people in Ireland today are living with Diabetes, Asthma, COPD or Cardiovascular disease. This is projected to increase by 4% annually. This represents a major challenge for the health services, society and the economy. To meet these challenges the HSE’s Clinical Strategy and Programme Health and Well-being team have designed and supported the implementation of models of Integrated Care (IC) for management of people with each of these chronic diseases. Practice change implemented : Since 2015, 61 chronic disease IC posts have been secured through the programme to support the transfer of care from secondary to primary care for people with a chronic illness. These include innovative IC nurse specialists for each of the chronic diseases based in the community and serving clusters of General Practices linking them to the local specialist services. They also include community podiatrists to implement the integrated diabetes foot care model, dietitians and physiotherapists to ensure accessible local structured education in diabetes and pulmonary rehabilitation. This represents a significant change in practice for care providers. Aim and theory of change : The aim of the programme management function was the co-ordination and facilitation of this change. In the initial phase the Programme Managers spent time developing a strategy to help ensure successful implementation of these posts. Each of the stakeholders involved were identified. Roles and responsibilities in the implementation process were agreed with the relevant Divisions. The main resistor identified was the difficulty in overcoming the challenge posed by people‘s reluctance to change. The Programme Managers recognised that in order for the changes to be realised, the vision for these posts needed to be communicated. Meetings with all clinical disciplines and management were held, the benefits of the change for each of these groups were framed to inspire and motivate them to support the implementation. The Programme Managers ensured an inclusive approach was taken as the success of the project is dependent on collaboration amongst multiple individuals and groups to achieve its goal. Targeted population and stakeholders : People with chronic illness Advocacy groups Healthcare providers Healthcare Management Timeline : This project has been ongoing since 2015. All 61 chronic disease posts will be in place by March 2017. Highlights (innovation, Impact and outcomes) Innovation: Co-design of integrated services across Clinical Programmes, National Directorates, service providers and functions Development of new governance structures for the implementation of chronic disease IC services New documentation developed e.g. job descriptions, Terms of References, reporting structure models. Impact: Reinforced the need for IC services for chronic disease Presented opportunities for engagement and knowledge sharing between stakeholders from different parts of the system where previously there was limited overlap Introduced new ways of working for Programme Managers Enhanced knowledge of the potential barriers to service integration including infrastructural challenges e.g. IT, communications, physical space, equipment. Demonstrated the importance of the National Clinical Advisor & Group Lead role in providing leadership for a co-ordinated approach to chronic disease management across these 4 diseases Outcome: Key performance indicators are currently in development which once evaluated will assist in demonstrating the effects of these posts on services Sustainability : Participation of multiple stakeholders and the shared learning gained will contribute to success. Project aligned to Government policy for IC. Transferability : Approach and learning on the design and implementation can be transferred to future initiatives by the IC Programme (ICP) for the Prevention and Management of Chronic Disease, and other ICPs. Conclusion & Discussion : Effective Programme Management is an essential element to supporting Implementation of IC. Lessons learned : Importance of an inclusive, collaborative team based leadership approach in introducing system wide change.
机译：简介：今天，爱尔兰约有100万人患有糖尿病，哮喘，COPD或心血管疾病。预计每年将增长4％。这对卫生服务，社会和经济构成了重大挑战。为了应对这些挑战，HSE的临床策略和计划健康与幸福团队设计并支持了综合护理（IC）模型的实施，以管理这些慢性病中的每一种。已实施实践更改：自2015年以来，通过该计划确保了61个慢性病IC职位，以支持将慢性病患者的护理从二级保健转移到初级保健。其中包括针对社区中每种慢性病的创新型IC护士专家，以及将其与当地专家服务联系起来的全科医学服务群。他们还包括实施综合性糖尿病足部护理模型的社区足病医生，营养师和物理治疗师，以确保在糖尿病和肺康复方面可以进行局部的结构化教育。对于护理人员来说，这代表了实践上的重大变化。变更的目的和理论：计划管理职能的目的是协调和促进这种变更。在最初阶段，计划经理花时间制定策略，以帮助确保成功执行这些职位。确定了每个涉众。与有关司商定了执行过程中的作用和责任。确定的主要阻力是克服人们不愿改变所带来的挑战的困难。计划管理者认识到，为了实现更改，需要传达这些职位的愿景。举行了与所有临床学科和管理人员的会议，为每个小组的变更带来了好处，以激励和激励他们支持实施。项目经理确保采取包容性方法，因为该项目的成功取决于多个个人和团体之间的协作以实现其目标。目标人群和利益相关者：慢性病患者宣传团体医疗保健提供者医疗保健管理时间表：该项目自2015年以来一直在进行。所有61种慢性病职位将在2017年3月到位。重点（创新，影响和成果）创新：跨临床计划，国家总局，服务提供者和职能的综合服务设计，开发用于实施慢性病IC服务的新治理结构职位描述，职权范围，报告结构模型。影响：加强了对慢性病的IC服务的需求提出了来自以前重叠很少的系统不同部分的利益相关者之间参与和知识共享的机会引入了计划经理的新工作方式增强了对服务集成潜在障碍的认识，包括基础设施挑战，例如IT，通讯，物理空间，设备。证明了国家临床顾问和小组负责人在领导这4种疾病的慢性疾病管理协调方法方面的重要性。结果：目前正在开发关键绩效指标，一旦对其进行评估，将有助于证明这些职位的效果关于服务的可持续性：多个利益相关者的参与和共享的学习经验将有助于成功。该项目符合政府的IC政策。可移植性：IC预防和管理慢性病计划（ICP）和其他ICP可以将有关设计和实施的方法和知识转移到将来的计划中。结论与讨论：有效的计划管理是支持实施IC的基本要素。经验教训：引入包容性，基于协作团队的领导方法在引入系统范围的变更中的重要性。

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