Six Aims for Health Care System (Institute of Medicine, 2001) 1. Safe: avoiding injuries to patients from the care intended to help them 2. Effective:

환자중심의료 Patient-centered Care 의료관리학교실 김 윤 1

Six Aims for Health Care System (Institute of Medicine, 2001) 1. Safe: avoiding injuries to patients from the care intended to help them 2. Effective: providing services based on scientific knowledge 3. Patient-centered providing care that is respectful of and responsive to individual patient preferences, needs and values, ensuring that patient values guide all clinical decisions. 4. Timely: reducing waits and harmful delays 5. Efficient: avoiding waste 6. Equitable 2

환자중심의료 Patient-Centered Care (PCC) vpatient-centered care = Patient-centered communication = Patient-centeredness v 의료의패러다임의변화 u "disease-centered" à "patient-centered v 질병중심모형 (disease-centered model) u 의사가전문성에근거해서환자진료에대한모든결정을내림 v 환자중심모형 (patient-centered model) u 환자자신의진료에관한결정에적극적으로참여 u 환자요구 (need), 선호 (preferences) 를진료관한결정에반영 치료법을선택할수있을경우 예 > 전립선비대증, 백내장 3

환자중심의료 : 발상의전환 4

환자중심의료 v 환자중심의료 u 환자우선 (patient, first) u 환자의권리와책임을동시에강화 권리 : 알권리, 통제권, 더나은진료 의무 Informed consumer: 자신의질병이해 건강한생활행태와합리적인의료이용 적절한수준의진료비본인부담 v 모든이해당사자들에게이득이될수있음 u 환자 : 더나은서비스, 건강수준향상 u 의료제공자 : 질향상, 의료사고감소 u 보험자 : 효율성증가로인한진료비감소 u 기업 : 보험료부담감소 5

환자중심의료 vthree core values 1) considering patients needs, wants, perspectives and individual experiences 2) offering patients opportunities to provide input into and participate in their care 3) enhancing partnership and understanding in the patient physician relationship vactions u interpersonal behaviors utechnical interventions uhealth systems innovations. 6

PCC Guiding Principles (WHO) 1. Appropriate care 2. Informed choice 3. Customized services: patient needs, values and preferences 4. Patient participation in decision-making 5. Evidence-based, ethical, and culturally and psychosocially sensitive decision-making 6. Service setting fitted in patient s unique situation 7. Team capacity building of health providers to be responsive to patient needs 8. Patient education for positive care-seeking behavior 9. Quality of care and outcome driven health care 10.Consumers/provider participation in policy development 7

Patient participation in decision-making vprinciple 4 u Patients are encouraged to be full and active participants in decision-making in accordance to their wishes about their care, and knowledge is shared fully and freely. vpatient participation in decision-making u Little evidence 8

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v 환자 외래진료과정에서환자참여확대 u 여러가지문제를가지고외래 / 입원진료를받음 u 자신의관심사, 근심, 두려움을적극적으로얘기하지못하는경우많음 u 환자가자신의관심사, 근심을얘기하지못하면만족도와진료결과부정적영향 v 환자참여확대를위한환자역할강화 technology can help uagenda cards u what matters? 외래진료전환자의증상, 주호소등환자가기록 10

Agenda Cards: 당뇨병 v 환자들이의료진과효과적으로의사소통할수있도록지원 v 당뇨병진료의 6 가지영역별로주요이슈를카드작성 u Progress and Change u Food and Eating u Medication and Treatment u Emotions and Feelings u Health u Relationships v 예 > Medication and Treatment section (5 장 ) u I forget to check my feet u Sometimes the medical terms confuse me u Taking my medication is difficult u I worry about my eyes u My blood test results are confusing 11

Agenda Cards: 당뇨병 12

환자관점측정도구 : 전립선비대증사례 vsymptom severity index: AHRQ 지원연구 u 환자증상과중증도측정 u 의료진이단시간내에환자상태를고려한치료방안추천가능 관찰, 약물치료, 수술 13

v Principle 8 Patient education for positive care-seeking behavior u Education at the community and facility levels is needed to support people to adopt positive care-seeking behaviour and become effective users of health services. v Hospitals/clinics u Short consultation time: about 5 min u Patient education for care-seeking behavior is rarely done v Public health agency: health center/subcenters u Provision of patient education for chronic disease patients, aged people, cancer patients v National health insurance coporation (NHIC) u Case management program Chronic disease patients High cost, high volume patients u Consumer health information system Web portal for health information HRA (health risk appraisal) based health exam results Provider information: 14

How s Your Health? 15

환자 스스로돌보기 지원 Providing Self-management Support v 스스로돌보기의중요성 u 대부분의만성질환관리의대부분은병원밖에서이루어짐 u 환자스스로돌보기가진료결과에중요한영향 u 환자스스로돌보기능력을강화하는것이중요 환자교육 : 이것만으로는효과적이지않음 v 스스로돌보기지원핵심요소 u Collaborative goal setting uaction planning 도구 : How s Your Health? u 환자와함께목표와실행계획을수립해야함. u 구체적이어야함 - 언제, 어디서, 무엇을, 어떻게 16

Quality and outcome driven healthcare v Principle 9 v v u u u u Quality of care and better health outcomes are the governance drivers of health care institutions. Cost driven healthcare system Fee for service payment = resource based reimbursement Government: cost containment >> quality improvement Provider Increase service volume Focus on more profitable service: high technology tests/procedures Policy initiatives for quality driven healthcare u Growing number of quality assessment programs and disclosure of provider performance u Mandatory hospital accreditation program since 2004 u National quality assessment (HIRA) 01~04: Appropriateness of prescription, Cesarean section, TKA Transfusion appropriateness and safety, 2005: AMI, CABG, PCI 2006: Stroke u Pay for performance project (2007) 17

우리나라대형병원의대형병원의중증도중증도보정보정사망비

진료질과질과진료비진료비상관관계 : 우리나라 CABG 사례 v 상위 90% 진료비 : 하위 10% 진료비 = 359 만원 :155 만원 = 2.3 배 v 하위 90% 질수준 : 상위 10% 질수준 = 78% : 88% =10% Ç 요양기관별평균진료비기관평균급여비 ( 원 ) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 Low Quality High Cost (A) Low Quality Low Cost (C) High Quality High Cost (B) High Quality Low Cost (D) 0 60.0% 70.0% 80.0% 90.0% 100.0% 질평가등급 1 9

Mechanism of improving quality: Two pathways Performance Measurement & Public Reporting Pathway(1) Knowledge about Performance Knowledge about Process and Result Pathway(2) Consumer Purchaser Referring clinician Hospital Clinician Selection & Accountability Motivation for Improvement Performance improvement 20

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환자진료의진료의조정 Coordinating Care Between Settings v 진료조정의중요성 u 여러의료기관에서다양한의료진으로부터진료를받음 u 진료정보의교류부재 정확한진단과치료저해, 중복검사및처방 v 진료코디네이터 v 실용적도구 u 표준화된진료의뢰서 u 표준화된인수인계서 u 환자진료요약서제공 22

Thank you