PDF(Pubmed)
Abstract：
Here, we present two real-world examples of how a prioritised, person-centred, multiple health condition approach - also termed a multimorbidity approach - has been applied to long-term condition management in general practice in Greater Manchester. The first example is the implementation of targeted multiple health condition reviews via a population health management approach across general practice in the City of Manchester. The second example is the development of a person-centred risk stratification tool, focused on unmet cardiovascular need, called \'CVNeed\'. This tool provides a unique approach to highlighting the highest unmet need and, thus, the largest return on investment to the system from proactive efforts. These examples demonstrate how a person-centred, multiple health condition approach to long-term condition management, enabled by data intelligence to drive prioritisation of clinical need, can help to address longstanding health inequalities and unwarranted variation in health outcomes. This work also highlights the potential for integrated care systems (ICS) to work collaboratively to tackle health inequalities at a system, locality and neighbourhood level, thus making significant strides toward achieving the vision set out in the Greater Manchester Integrated Care Partnership (ICP) Strategy.
摘要：
这里,我们展示了两个现实世界的例子，以人为本,多健康状况方法-也称为多发病率方法-已在大曼彻斯特的一般实践中应用于长期状况管理。第一个例子是在曼彻斯特市的一般实践中，通过人口健康管理方法实施有针对性的多种健康状况审查。第二个例子是以人为中心的风险分层工具的开发,专注于未满足的心血管需求，名为“CVNeed”。该工具提供了一种独特的方法来突出最高的未满足需求，因此，积极努力对系统的最大投资回报。这些例子展示了如何以人为本，长期病情管理的多种健康状况方法，通过数据智能来驱动临床需求的优先级，可以帮助解决长期的健康不平等和健康结果的不合理变化。这项工作还强调了综合护理系统（ICS）协同工作以解决系统中的健康不平等问题的潜力，地区和邻里水平，从而在实现大曼彻斯特综合护理伙伴关系（ICP）战略中提出的愿景方面取得了重大进展。
