Annual Conference Supplement 2008: The Chronic Care Model as vehicle for the development of disease management in Europe

摘要

The Chronic Care Model (Wagner, WHO) aims to improve the functioning and clinical situation of chronic patients by focussing on the patient, the practice team and the conditions that determine the functioning of the team.The patient is the most important actor who must be stimulated proactively by a competent, integrated practice team. Six interdependent conditional components are essential: health care organisation, delivery system design, community resources and policies, self-management support systems, decision support and clinical information systems.While the Chronic Care Model focuses on quality and effectiveness of care, disease management programmes underline more the efficiency of care. These programmes apply industrial management principles in health care. Information about process, structure and outcome is gathered and used systematically and human and material sources are used efficiently.There is evidence that the approaches of the Chronic Care Model and disease management can be integrated. Both approaches underline the need of information and focus on the patient as the main actor to improve and that a balance can be found between effectiveness and efficiency. Ideas will be given how the Chronic Care Model can be used as a framework for the development of a European way of disease management for people with a chronic condition.