啦操全科家庭醫(yī)學(xué)課件co-managed care for the chronic diseases by gp with specialists through mobile internet

1、 Co-Managed Care for the Chronic Diseases By GP with Specialists Through Mobile InternetTaking dyslipideamia for exampleYAPING DU INSTITUTE OF SOCIAL MEDICINE AND FAMILY MEDICINEZHEJIANG UNIVERSITY SCHOOL OF MEDICINE2015.12.14WHAT ARE THE MAIN PROBLEMS FOR THE MANAGEMENT OF THE COMMUNITY CHRONIC DIS

2、EASE?ResidentConsciousness is not enoughDoctorPay more attention to treatment (specialist) than preventionGPLess GP, Lower LevelHospitalOvercrowded at Large hospitals, CHSC desertedEVOLUTION OF POLICE (SOCIAL SECURITY)Past policeModern policeEVOLUTION OF DOCTORS (SOCIAL HEALTH)Doctor in the 50s.Mode

3、rn doctorHow many families are there have person with three high?How will you to let your relatives be like this!BEDSORE IN HIPSROTTEN TO WHERE PRESSED!SMALL HOLE WILL E A BIG ONE THOUGH NURSED CAREFULLY!GANGRENE IS THE END OF THE FOOT!DIABETIC NEPHROPATHY-GLOMERULAR SCLEROSISRENAL CORTEX PALE AND T

4、HICKFUNDUS HEMORRHAGEThe three high cannot be cured from the beginning, unless the life style of patients with reversal!Doctors symptomatic treatment can not solve the problem!Management for chronic disease is more important! The key is how to manage?CONTROLLING FOR THE COMMUNITY DYSLIPIDAEMIA (CLAS

5、S EXPERIENCE FIRST)IDEA FOR THE LIPID-KEEPER安卓版二維碼RELATED NOTIONDyslipidaemiaTotal cholesterol （TC）5.18mmol/LTriglyceride（TG）1.70mmol/LLow density lipoprotein（LDL）3.37mmol/LHigh density lipoprotein（HDL）1.04mmol/LICVD Risk Appraisalischemic cardiovascular diseaseRisk Assessment for coming 10 years on

6、 adults with no symptoms by combination with gender, age, systolic blood pressure, body mass index (BMI), total cholesterol, smoking, diabetes and other factorsBasis of hierarchical managementCODE FOR DYSLIPIDAEMIAE78.001Hypercholesterolaemia E78.101Pure hyperglyceridaemiaE78.203Mixed hyperlipidaemi

7、aE78.501Hyperlipidaemia, unspecified E78.602HypoalphalipoproteinaemiaE78.603Hypobetalipoproteinaemia (familial)E78.604Hypolipoproteinaemia BLOOD LIPIDS ARE HARD TO CONTROLNeither painful nor itchingDetection is difficult, many indicators, a lot of factors, effect slowlyCHINA ADULT DYSLIPIDEMIA PREVE

8、NTION AND TREATMENT GUIDELINES is far from the grassroots level Data collection difficultiesPatient: inconvenienceDoctors: unwilling (time and economy)CO-CARE FOR THE THREE HIGH BRING WITH EFFICIENCY MOREBLCBD ManagementBPBGBP, BG and BL are three brothers. Management for them are indispensable1+ 1+

9、1 31+ 1+1 3 EFFECT RESOURCES REQUIREMENTS FOR MANAGEMENT OF DYSLIPIDAEMIA IN COMMUNITYGradePatientGP1BL: YearlyBP and BMI: QuarterlyYearly2BL: QuarterlyBP and BMI: MonthlyQuarterly3BL: MonthlyBP and BMI: WeeklyMonthlyEFFECTIndex Prevention Right Data collection, Transference fasterSelf Building, man

10、aged by teamCost , Operation easyPracticing Biopsychosocial Medicine 2015.12.14BackgroudTreating each patient as a unique personindividual historyeducation levelbehavioral stylecultural heritagehealth belief systemset of vulnerabilitieslives in a particular communitypresents with a specific problem

11、can present a formidable challenge.It is a challengetraditional medical education has not adequately prepared the practitioner to meet The first shift (PARADIGMS) Before 1910physicians were trained almost exclusively in an apprenticeship experience. Typically, the aspiring doctor would be taken unde

12、r the wing and tutelage of an established clinician and then, on the mendation of that clinician, would be examined by a sanctioned organization such as the State Medical Society and awarded a medical doctor degree if the organization found this individual ready to embark on a medical career.The fir

13、st shift (PARADIGMS) After 1910 university model, bringing medical schools into the more traditional higher-education, graduate school format. medical investigators engaged in scholarly inquiry as dictated by the tenants of the scientific method. led to standardization of the body of medical knowled

14、ge emphasis on science the use of reductionist methodology in areas of academic exploration. Spectacular Discoveries in BiomedicineApplying the scientific method to medical education and medical inquiry led to spectacular discoveries in biomedicine pushed back the frontiers of our understanding of p

15、hysiology and pathology.Daily, we are learning more and more about the functioning of the human organism at the cellular, protein, and genetic levelThe Needs to Reshape Dramatic proliferation of knowledgeThe effects of burgeoning technologyThe information accessible on the internetThe focus on evide

16、nce-based medicineThe sociologic changes within the community that encourage self-help programsIncreased personal longevity with its itant chronic illnesses The crippling flaw of the model This approach, which is ideally suited to scientific investigation, has created an inappropriately dichotomous

17、situation with regard to patients. Patients are considered either to have or not to have a given diseaseDiseases are treated as independent entities amenable to categorization and are presumed to have a specific causeThe physicians task is to diagnose and prescribe a cure that will alter the natural

18、 course of disease In this process, however, there is a loss of many of those human qualities that compose the patients total beingMedical scholars have questioned the systemPatients have expressed dissatisfaction with this one-dimensional (biomedical) approach to multidimensional problems This publ

19、ic dissatisfaction indicates that a more rational way to both investigate and deliver health care services requires the reengagement of the psyche and the soma. Questioned the model Role of Family PhysiciansHave had to deal with the vagaries of an undifferentiated patient population as their daily b

20、ill of fare. Working at the interface of the biomedical, behavioral, and social sciences, these physicians must be facile in the reductionist approach to delving into the biomedical nature of a patients problems but also must integrate an understanding of the multiple influences that work on a patie

21、nt to produce a biomedical dysfunction. Role of Family PhysiciansOn the micro levelDeal with patients and their biomedical problemsOn a macro levelDeal with patients and their complex relationships with others, their communities, and the world community. A failure to comprehend this dualistic role h

22、as the potential to fatally flaw any practitioners best clinical efforts.Second Shift (Paradigm)It derives from the notion that the contemporary physician has multiple responsibilities, including understanding of the biomedical coupled with integrating of the behavioral and social into the comprehen

23、sive management of any patient and his problems.This reorientation is already well under way and will rival the shift in emphasis in medical education Primary care practitioners must adapt to the various needs of patients and changing care technologies, and they must be prepared to offer a full bask

24、et of servicesUbiquity of Stress Regardless of the origin of a patients dysfunction， the ultimate result is that a patient presents to a family physician with symptoms and a diminished ability to deal with “the hand fate has dealt.” a mechanical failure of the biomedical system a physical manifestat

25、ion of some other problemA consistent companion of the patient in this process is stress.May be generated by a biomedical dysfunctionthe biomedical dysfunction may be generated by the patients reaction to stress. Ubiquity of Stress It is the patients lack of tolerance for the symptoms or anxiety abo

26、ut the symptoms that frequently triggers the visit to the physician.How that patient deals with the stress associated with his problem will determine the patients ultimate e. Physician must be aware of, and understand, the impact of stress on the overall problem presented by the patientStress Is end

27、emic in 21st CenturyNew StressTerror alerts at home and from abroadFinancial crisisThe price of housingUnemploymentPoisoning powdered milk incident (Melamine) Heavy smog (fog and haze)The stress for doctor come from SCI articles and public health servicePeople feel OverwhelmedOver stimulatedOut of c

28、ontrolTurn off all feelings and develop somatic complaintsPositive social power of physiciansFive of the most predominant of these powers are possessed by physiciansReward powerprescribe medications , certify to patients illnesses, control many resources that patients requireCoercive power coerce go

29、od behavior and compliance from a patient exerting the threat of a negative e Expert powerReferent power Legitimate power Principle 1_Listening to and helping patients edit their storiesRestoring the patients power in five major componentsExpectation of receiving help Therapeutic relationship Obtain

30、ing an external perspective Encouraging a corrective experience Opportunity to test reality repeatedly the physician is the patients port in a storm. The physician is the supportive listener and occasional commentator Principle 2_Expanding not shrinking Patients are likely to have stress and will re

31、spond accordinglythey do not need a psychiatristIt is the responsibility of the physician to address each and every component of a patients illness, be it organic, psychologic, or related to the social environmentHold the greatest promise for the physician to integrate the biomedical, psychological,

32、 and social expand the patients behavioral repertoire and sense of personal power A reasonable expectationThe physician will restore the patients premorbid level of functioning and enhance her sense of self-esteem.Principle 3_BATHEing the patientThe acronym BATHE triggers four questions and an appro

33、priate response B Background What is going on in your life? will elicit the context of the patients visitA Affect (the feeling state)How do you feel about that? or What is your mood? allow the patient to report the current feeling stateT TroubleWhat about the situation troubles you the most? helps b

34、oth the physician and the patient focus on the situations subjective meaningH HandlingThe answer to the question How are you handling that? gives an assessment of functioningE EmpathyThe statement That must be very difficult for you legitimizes the patients reactionPrinciple 4_Ownership The physicia

35、n does not assume responsibility for the patients particular situation but rather assesses the patients circumstances to make therapeutic suggestions that enable the patient to deal with her problem more effectivelyThe patient continues to own her problem, but the physician is better able to assist

36、that patient in the resolution of the problem because the physician has a complete and comprehensive understanding of its derivationOwnership of the problem remains with the patient, who now understands that the physician is there to helpThe physicians ability to intervene effectively is enhanced by

37、 the psychosocial assessment, revealing the array of influences working on a given patient Principle 5_Therapeutic TalkBATHEing the patient creates a highly therapeutic relationship and often elicits evidence of anxiety or depression connected with psychosocial problems The physician is now in a pos

38、ition to treat these conditions with therapeutic talk, along with medication, if appropriatePrinciple 6_GIVING ADVICEIt is better to make patients aware of their own strengths and their ability to assess and exercise their own options. Principle 7_Distinguishing among thoughts, feelings, and behavio

39、rsPatients must learn to differentiate among thoughts, feelings, and behavior. Thoughts are related to our beliefs and the stories that we tell ourselves about the world, other people, and ourselvesThey are the judgments, expectations, generalizations, and unfounded prognostications we all makeFeeli

40、ngs are emotional responses to a situation based on thoughts and judgments Behaviorconsists of the actions we takeHelping patients focus on their behavior and make positive adjustments in their lifestyle Principle 8_Assuming that there are optionsWhen patients are overwhelmed by the circumstances of

41、 their lives, they lose sight of the fact that they still have choices The physicians suggestion that there are always options and that the patient needs to explore them cues the patient in a positive directionIt is not the physicians task to generate these options; rather, it is the patientsThe phy

42、sician communicates the expectation that the patient can and will do this and will return to report the resultsThis therapeutic intervention helps patients to be more open to possibilitiesto look at their world, including themselves, in a new wayto e aware of having choicesPrinciple 9_Changing the s

43、toryPhysicians can point out that there are four healthy options for handling a bad situation:Leaving itthis dictates exploring the best and worst possible es that might result.Changing itthis requires an investigation of what is possible and what additional resources must be brought to bear.Accepti

44、ng it as it isrecognizing that, if it could be different, it would be different.Reframing itfinding a way to interpret the situation as a positive.Principle 9_Changing the storyTherapeutic talkis that direct conversation that focuses patients on their strengths and choices. It changes the story that

45、 patients are inadequate and that no one cares. Instead, it makes patients feel competent to deal with the circumstances of their lives and makes them feel good about themselves and about their relationship with their physician.Principle 10_Dealing with difficult patientsFour stereotypes of hateful

46、patientsConsistently trigger negative feelings in physicians, who cannot satisfy their endless demands and complaints. Dependent clingersphysicians must limit the time they spend with patients who arouse negative emotions to less than 15 minutes Manipulative help-rejectorsEntitled demanders Self-des

47、tructive deniers. The Chronic Complainer There are real differences between hypochondriacs, who are concerned about the state of their health (the worried well), and chronic complainers, who have multiple complaints, demand to be seen frequently, rarely get better, and never appreciate the physician

48、s efforts on their behalf. Here, again, the best treatment is to acknowledge their suffering and to recognize the futility of trying to alleviate it. These patients seem to need their disease to function at all. The Depressed PatientIt is depressing to acknowledge that depression not diagnosed or tr

49、eated by the primary care physician often results in long-lasting symptomatology, decreased quality of life, and suicide. Even mild to moderate depression affects peoples lives negatively. BATHEing the patient results in the diagnosis, after which depression can be treated effectively using brief se

50、ssions, with or without medication. Specific suggestions for a variety of brief and effective interventions for managing patients suffering from depression, anxiety, and other emotional upheavals can be found in The Fifteen Minute Hour. Physician, treat thyselfIncorporating the psychosocial aspects

51、of medicine into daily practice can be challenging but extremely gratifying, provided that the physician observes a number of basic rules for survival. not to take responsibility for things you cannot control to take care of yourself, or you cannot take care of anyone else; to recognize that you hav

52、e to start where the patient is, which means that it is crucial to do a psychosocial assessment along with a biomedical one. Applying these principles is the essence of practicing biopsychosocial medicine. In what context a disease should be addressed in order to fully understand it social factors a

53、ffect health include: AgeRaceGenderEconomic statusLevel of education In the following statements, which are correct: Women uniformly live longer than menMale fetuses are aborted more often than femaleMales have a higher risk of death under age 5 than femalesWomen use care more than men and believe they are sickerWomen exhibit less stress than men In the following statements, which are correct except: There is a salutary effect of