Yeungnam Univ J Med.  2019 Jan;36(1):1-7. 10.12701/yujm.2019.00073.

Implementation of a care coordination system for chronic diseases

• Lee JJ
• Bae SG

• KMID: 2434092
• DOI: http://doi.org/10.12701/yujm.2019.00073

Abstract

The number of people with chronic diseases has been increasing steadily but the indicators for the management of chronic diseases have not improved significantly. To improve the existing chronic disease management system, a new policy will be introduced, which includes the establishment of care plans for hypertension and diabetes patients by primary care physicians and the provision of care coordination services based on these plans. Care coordination refers to a series of activities to assist patients and their families and it has been known to be effective in reducing medical costs and avoiding the unnecessary use of the hospital system by individuals. To offer well-coordinated and high-quality care services, it is necessary to develop a service quality assurance plan, track and manage patients, provide patient support, agree on patient referral and transition, and develop an effective information system. Local governance should be established for chronic disease management, and long-term plans and continuous quality improvement are necessary.

Keyword

Chronic disease; Patient care management; Referral and consultation; Transitional care

MeSH Terms

Chronic Disease*
Humans
Hypertension
Information Systems
Patient Care Management
Physicians, Primary Care
Quality Improvement
Referral and Consultation
Transitional Care

Reference

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