Integrated Chronic Care Model And Strategy Research For People With Chronic Diseases In Chinese Rural Area

[Purpose]1. Under the perspective of health integration, describe the un-integration situation from three aspects:macro-level, meso-level, and micro-level;2. Evaluating effect and its influencing factors of the integrated intervention in health services;3. To build a suitable Integrated Chronic Care Model (ICCM) and to discuss the integrated service strategy for the prevention and control of chronic diseases.[Methods]1. Intervention Study Based on the research’the Effectiveness and Efficency of the integrated care in Chinere rural aera’funding by CMB(11-069).2. The econometric analysis method To evaluation of continuous variables by Difference in Difference model (DID); To evaluate the intervention effect of the blood pressure values by Repeated Measurement Variance Model; To analysis of quality of life, blood pressure control, the influence factors of medication adherence by Multiple Level Model (MLM); To describes the interaction relationship by Structural Equation Model(SER).3. The method of establishing model To build ICCM by Entity-relations and to build one of the "one-stop" integrated service by IDEF3(Integrated DEFination3).[Results] 1. The NCD’s management and epidemic situation(1) The management and service delivery status. The rate of hypertension crude drugs was63.73%,47.36%level of management awareness. The main way of follow-up was outpatient follow-up (74.97%) and on-site follow-up (22.63%).(2) The QOL and behavior risk factors. The patient were at the low-level in QOL, self-efficacy and Behavior risk factors. Live monitoring object is lower than other living situation at the indicator of QOL (P=0.0.19) and self-efficacy(P<0.001), while the higher the degree of cultural awareness is higher (P<0.001). The male rate of smoking and drinking alcohol is far higher than women (P<0.001).2. The service status of unconformity chronic diseases in rural areas(1) Micro-integration:doctor-patient integration TI is higher than SI, SI higher than NI:1) Continuity of follow-up service, personalized follow-up services and the doctor-patient interaction were more actively (P<0.001).2) Medication adherence:TI is higher than SI, SI higher than NI (P=0.159).(2) Meso-integration:management integration and Health service integration1) management integration:Lack of personnel, ability is insufficient,; lack of motivation, underpowered, service enthusiasm is not high, participation is not enough; The lack of information system, decision support is insufficient, lack of channels of information transmission and sharing mechanism between institutions;2) Health service integration: NCDs patients need to accept the "COC", which were provided by different agencies.(3) Macro integration:1) financing system restricted the service system development.2) three-level health service network within each agency as an independent subject negotiations, signing and guarantee system. Guarantee system for multiple institutions set up payment and total costs respectively, seriously impact on the efficiency and security.3. Analysis of integrated service intervention effect(1) Blood pressure control effect:1) SBP:Overall, TI was better controlled than SI (P<0.001);2) DBP:SI was better controlled than NI (P=0.009).(2) QOL:Generally TI is4.266higher than the NI (P=0.029), while there is no different within:TI, SI, and NI in PH. But the TI was better controlled than NI in MH (P=0.011).(3) Awareness and self-efficacy: TI was better than NI in awareness (P=0.032) while: TI and SI, SI was better than NI (P=0.044)in Self-efficacy.4. Intervention effect factors analysis(1) QOL:Age (P=0.0494), education (P=0.0067), intervention group (P=0.032) and self-efficacy (P<0.001).(2) Blood pressure control:SBP:repeated measurement (P<0.001), age (P=0.049), intervention group (P<0.001).(3) Statistically significant factors in Medication compliance:awareness (P=0.003), intervention group (P<0.001), gender (P=0.022).(4) SER:the level of education/behavior intervention, awareness, self-efficacy, quality of life.5. ICCM(1) Incentive compatibility between stakeholders1) Direct stakeholders interests:Biggest obstacle of incentive compatibility is from the department of health and medical institution.(2) ICCM1) Model entities and entity attributes:payer:implementing public health capital and health capital financing and the integration of management; provider:county tertiary prevention health care service network of vertical and horizontal "medical prevention integration""medical-medical integration".2) Relationship between entities:each subject is given priority to with each other constraints, the role of the relationship between incentives is complementary.(3) Treatment process based on the ICCM1) Entry:general practitioners (GP);2)"one-stop" services:prevention care, treatment, rehabilitation and hospice care;3) focus on the crowd:the focus of the crowd (individual centered service), high-risk patients with medication (group centered service). [Conclusions]1. Rural popular trend is still grim, chronic diseases management level needs to be further improved. Behavior risk factors are poorly controlled, health knowledge awareness is not high, and medication adherence is generally not high. Give priority to with outpatient follow-up service, health archives utilization rate is not high, the service lack of pertinence. The phenomenon of un-integration consists of patients-doctor un-integration, services un-integration, management un-integration, and system un-integration.2. Intervention played a role in improving the awareness, treatment adherence, self-efficacy, blood pressure control effect and quality of life. The recommended path: improve the level of education and awareness, then strengthen the patient’s self-management, and improve medication compliance, and to improve their QOL.3. Build ICCM with four main functions and the interaction relationship in it. Health outcomes and health total cost as the goal for all stakeholders should be established to achieve incentive compatibility. Doctor-patient integration, horizontal integration and vertical integration, organization integration, financing integration, system integration was recommended according to degree of integration.[Innovations and Limitations]Based on ICCM, we point out the unconformity overview chronic diseases in rural China:unconformity of capital financing channel; The service provides the unconformity; Security and provide system integration; Doctor-patient unconformity. And point out that the present stage split between medical insurance departments and tertiary prevention of health services is the two main body of the integration.This study uses a variety of econometric analysis method to eliminate confounding factors, while there are too much uncertainty affecting intervention factors in this study. In this study we use the high blood pressure as a case study, which has some limitations.