public policy development for caring chronic diseases

1. นพ. ชูชัย ศรชำนิ
chuchai.s@nhso.go.th
chuchai.sn@gmail.com
Facebook ,Twitter : Morchuchai 1

2.  a course of action or inaction (Heclo 1972)
 a course of action adopted and pursued by a government,
party, rulers, statesman (Oxford English Dictionary)
 a set of interrelated decisions … concerning the selection of
goals and the means of achieving them within a specified
situation … (Jenkins 1978)
 decisions taken by those with authority and responsibility for a
given policy area (Buse et al 2005)
any course of action followed primarily because it is expedient or advantages
in a material sense
2

3.  นโยบายด้านสาธารณสุข (Public Policy) นโยบายเพื่อการดาเนิน
สาธารณสุข ที่เป็นเรื่องที่เกี่ยวข้องทางด้านสุขภาพโดยตรง
 นโยบายสาธารณะเพื่อสุขภาพ (Healthy Public Policy) นโยบาย
สาธารณะที่แสดงความห่วงใยอย่างชัดเจนในเรื่องสุขภาพ พร้อมที่จะรับผิดชอบ
ต่อผลกระทบทางสุขภาพ ที่อาจเกิดขึ้นจากนโยบายนั้น ขณะเดียวกันก็เป็น
นโยบายที่มุ่งสร้างเสริมสิ่งแวดล้อมทั้งทางสังคม และกายภาพที่เอื้อต่อการมีชีวิตที่
มีสุขภาพดี และมุ่งให้ประชาชนมีทางเลือก และสามารถเข้าถึงทางเลือกที่
ก่อให้เกิดสุขภาพดีได้

4. 4
• นโยบำยของรัฐบำล-แถลงกำรณ์ของนำยกฯ
• กฎหมำย พรบ พรก กฎกระทรวง ประกำศ
• แผนพัฒนำเศรษฐกิจและสังคมแห่งชำติ
• แผนแม่บทแห่งชำติ
• บัญชียำหลักแห่งชำติ
• ชุดสิทธิประโยชน์ของระบบประกันสุขภำพ
• กฎหมำย กฎระเบียบในระดับจังหวัด
• แนวทำงระดับเขตตรวจรำชกำร
• มติของคณะกรรมกำรจังหวัด อำเภอ
• แนวทำงกำรคัดเลือกเวชภัณฑ์ของโรงพยำบำล
• Clinical Practice Guidelines, Standard
Operating Procedures (SOP) เช่น Laboratory
manuals
•กำรจัดงำนประชุมวิชำกำร
นโยบำยระดับชำติ
นโยบำยระดับพื้นที่
นโยบำยระดับองค์กร

5. 5
Input Process
By product
Input
Human resources
Financial resources
Instruments
Technical knowledge
Output
Outcome Effect Impact
Short term Long term

6. 6
Walt G and Gilson L, Reforming the health sector in developing countries: the central role of
policy analysis, Health Policy and Planning 1994; 9: 353-70
Actors
Context
Content Process

7. ฉุกเฉิน
โรค
เรื้อรัง
สุขภาพจิต
พัฒนาการ
เด็ก
ผู้สูงอายุ
ฟื้ นฟูผู้
พิการ
วัยรุ่น
ภาคี
สุขภาพ
มูลนิธิสาธารณสุขแห่งชาติ 2553

8. Performance framework (WHO, 2000)

10. Source: World Health Organization. Everybody’s
Business: Strengthening health systems to improve
health outcomes—WHO’s Framework for Action.
Geneva: WHO, 2007, page 3.

11. Health Policy and Healthy Public Policy Development
Diseases or Service Response
Health System Response

12. .
.
.
.
 Insurance Model
 Utilization review, quality assurance function
 Compliance and access orientation
 No integration
 Care Delivery Model
 Develop standard tools: CPG, care map
 Linear integration
 Security (Continuum Care) Model
 Community health care, optimum care site
 Continuous quality improvement
 Promote wellness and community health status
 Multidimensional integration
12

13. พัฒนาการทางเศรษฐกิจ สังคม เทคโนโลยี กับ
การพัฒนานโยบายความเข้มแข็งระบบสาธารณสุข “โรคเรื้อรัง”

14. 2005

15. Generation 2010 2020 2030
Baby Boomer
( 50 ปี ขึ้นไป)
6,462 - -
Gen X
(31 - 49 ปี)
15,742 15,742 -
Gen Y
(18 - 30 ปี)
3,750 3,750 3,750
Gen M
- 6,462 22,204

17. Prevalence Hypertension: 23% male, 21% female
All samples are hypertensive, >140/90 mmHg,
Effective coverage of hypertension,
adult >15 yr. 2003
Source: National Health Exam Survey
6
12
11
19
5
5
77
64
0% 20% 40% 60% 80% 100%
Male (N=7,544)
Female (N=7,580)
treated + well control Treated, not well controlled
Diagnosed, no treatment Not diagnosed

18. Prevalence DM: 6% male, 7% female
All samples have FBS, >126 mg/dl
Effective coverage of DM, adult >15yr. 2003
Source: National Health Exam Survey
9
15
24
34
2
2
66
49
0% 20% 40% 60% 80% 100%
Male (N=2,045)
Female (N=2,601)
treated + well control Treated, not well controlled
Diagnosed, no treatment Not diagnosed

19. 19
คนชั้นกลางในไทยปี 2533-2549
0
2
4
6
8
10
12
14
16
2529 2531 2533 2535 2537 2539 2541 2542 2543 2544 2545 2547 2549 2550
69-346 บาท/วัน
เส้นความยากจน-346 บาท/วัน
จานวนครัวเรือนชั้นกลาง แยกตาม 2 นิยามจานวนคนชั้นกลางอยู่ระหว่างนิยามทั้ง
สอง คือ 12-15 ล้านครัวเรือน

20. 20
ร้อยละครัวเรือนทุกกลุ่มทีมีอุปกรณ์อานวยความสะดวก
เทศบาล
นอกเทศบาล
17.59
21.19
22.89
26.74
57.71
60.77
68.02
78.51
85.73
88.14
91.04
96.44
0 20 40 60 80 100
รถยนต์ส่วนบุคคล
รถบรรทุกเล็ก / รถปิกอัพ / รถตู้
เตาอบไมโครเวฟ
เครื่องปรับอากาศ
เครื่องซักผ ้า
รถจักรยานยนต์
วิทยุ
เครื่องเล่นวีดีโอ / วีซีดี / ดีวีดี
ตู้เย็น
โทรศัพท์เคลื่อนที่
หม ้อหุงต ้มอาหาร
โทรทัศน์
4.81
5.19
7.12
19.70
41.56
56.64
66.63
74.54
77.68
81.77
83.01
94.71
0 20 40 60 80 100
รถยนต์ส่วนบุคคล
เครื่องปรับอากาศ
เตาอบไมโครเวฟ
รถบรรทุกเล็ก / รถปิกอัพ / รถตู้
เครื่องซักผ ้า
วิทยุ
เครื่องเล่นวีดีโอ / วีซีดี / ดีวีดี
โทรศัพท์เคลื่อนที่
รถจักรยานยนต์
หม ้อหุงต ้มอาหาร
ตู้เย็น
โทรทัศน์
ความต้องการสิ่งอานวยความสะดวกทาให้ตลาดสินค้าอุปโภค
บริโภคใหญ่และขยายตัว เช่น เครื่องใช้ไฟฟ้า ยานพาหนะ อาหาร
แปรรูป เกิดการผลิตและการจ้างงานในประเทศ
ครัวเรือนมีค่าใช้จ่ายที่เกี่ยวข้องกับ
การเรียนรู้เพิ่มมากขึ้น เช่น ด้านการสื่อสาร และการ
เดินทางในโอกาสพิเศษ รวมทั้งการลงทุนด้าน
คอมพิวเตอร์และเชื่อมต่ออินเทอร์เน็ต

21. 2533 2539 2540 2541 2543 2547
การบริโภครวม 65.9 62.8 62.6 63.3 63.2 63.6
• ภาคเอกชน 57.1 54.4 54.4 53.8 54.0 54.9
• ภาครัฐบาล 8.8 8.4 8.2 9.6 9.2 8.6
การลงทุนรวม 39.1 42.5 34.2 21.3 19.9 22.5
• ภาคเอกชน 33.2 32.1 22.7 12.1 12.5 16.4
• ภาครัฐ 5.9 10.4 11.6 9.2 7.4 6.1
ส่งออกสินค้าและบริการ 36.5 42.0 45.7 55.3 64.7 65.7
นาเข้าสินค้าและบริการ 41.54 49.2 44.3 38.8 49.8 54.0
ที่มำ : สศช.

22. ข้อมูล สำนักงำนคณะกรรมกำรอ้อยและน้ำตำล คัดจำกรำยงำนกำรสำธำรณสุขไทย พ.ศ. 2544-2547

23. % of Total 52.61 42.83
Rank Disease
DALY
('000)
% %
DALY
('000)
Disease
1 HIV/AIDS 645 11.3 7.4 313 Stroke
2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS
3 Stroke 332 5.8 6.4 271 Diabetes
4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression
5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease
6 COPD 187 3.3 3.0 125 Traffic accidents
7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer
8 Diabetes 175 3.1 2.8 118 Osteoarthritis
9 Cirrhosis 144 2.5 2.7 115 COPD
10 Depression 137 2.4 2.6 111 Cataracts
Male Female
DALY

24. 9.4%
8.1%
5.7%
5.5%
4.5%
3.7%
2.2%
1.7%
1.3%
0.9%
0.9%
0.5%
0.3%
0.3%
0.2%
13.8%
5.8%
5.1%
5.0%
4.2%
3.9%
2.3%
1.4%
1.2%
3.6%
1.4%
0.7%
0.7%
0.4%
0.3%
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%
Unsafe sex
Alcohol
Tobacco
Blood pressure
Not wearing helmet
Obesity
Cholesterol
Fruit & vegies
Physical inactivity
Illicit drugs
Air pollution
Water & sanitation
Malnutrition - int standard
Not wearing seatbelt
Malnutrition - Thai standard
% of total burden
2004
1999
ลำดับปัจจัยเสี่ยงที่ก่อให้เกิดภำระโรคจำกมำกไปหำน้อย ได้แก่ กำรมี
เพศสัมพันธ์ที่ไม่ปลอดภัย แอลกอฮอล์ บุหรี่ ควำมดันเลือดสูง กำรไม่
สวมหมวกและคำดเข็มขัดนิรภัย ภำวะน้ำหนักเกินและโรคอ้วน ระดับ
โคเลสเตอรอลในเลือดสูง กำรบริโภคผักและผลไม้น้อย กำรขำดกำร
ออกกำลังกำย กำรใช้สำรเสพติด มลพิษทำงอำกำศ กำรขำดน้ำสะอำด
กำรสุขำภิบำลและสุขอนำมัยที่ไม่เหมำะสม และภำวะทุพโภชนำกำร

26.  “Knowledge is power”
 Medical process: information
process
 Delocalised, distributed and
direct
 Decision support, information
management, identity
technology,
imaging, visualisation, sensors,
telemedicine
 The home as treatment location
 The Internet Patient

27.  Diagnosis, data analysis, reminders,
memory empowerment, ”second opinion”
 Interactive broschures, simulations, smart
objects, ”the digital doctor”
 Benefits patient participation, handle information
overload
 Problems: conservative, silent knowledge,
integration with patients and organisation

28.  Scanning + fast visualization
+ information fusion
 Non-invasive exploration
 Direct information to doctors
 Shorten the treatment chain,
reduce sidetracks
 Requires change in routines

29.  Trends
 More conditions measurable, smaller, cheaper, plentiful, more functions per chip
 More intimate and biological, both non-invasive and implanted
 Active ”smart” sensors/actuators, wireless communication
 Pathogen sensors, automated medication
 Moves the location of diagnosis and
treatment to the periphery
 Information overload,
privacy, security,
training

30.  Surgery supported by information
technology
 Remote surgery
 Direct visualisation
 Augmented reality
 Robotics
 Economy? Stumbles on
organisation issues

31.  More and more applications
 Faster recovery
 Faster surgery redistributes medical personell
 Need of a new kind of operating theatre?
 Strong link toVR and robotic surgery

32.  Regenerative medicine
 Rational drug design
 Bionics
 Genetic testing
 Vaccines
 Enhancing medicine

33.  Rational design
 Based on genomics, simulation and knowledge of
basic processes
 Generics threatened, business models in
pharma threatened
 Blurs the borders between palliative,
curative, preventative and enhancing
medicine

34.  Neurointerfaces rapid development (~300
electrodes, permanent)
 Prosthetic research underfinanced
 Large gains for small groups

35.  Cheap, fast genetic tests many
conditions
 How many wants to test? How does
the health system respond?
 Benefits: More individually adapted,
good for preventative medicine and
pharmacogenomics
 Problems: Interpretation, too much
faith in genetics, diagnosis develops
faster than treatment, breaks
information monopolies

36.  Reproduction as a right?
 We are willing to spend enormous sums on
our children and their health
 Genetic testing, preventative medicine
 Perinatal medicine

37.  Vaccines for treatment instead of just prevention
 Immune system control
 Vaccines against
 Allergies
 Diabetes
 Autoimmune illnesses
 Metabolic illnesses
 Cancer
 Narcotics

38.  The brain/mind increasingly visible
 New pharmacology + understanding of brain
leads to treatment of many mental disorders
 Hybrid therapies

39.  NBIC convergence
 Enhancement of previous technologies
 Reduced price
 Increased effectiveness
 Increased portability
 Active and smart devices and drugs
 Development gradual and enabled by
previous technologies.

40. Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305 Copyright ©2004 BMJ Publishing Group Ltd.

41. Population Screening
Using claims/clinical data to identify patients for
disease management
Patient Risk Management
Surveying patients about disease status/burden
to identify for disease management
Team-Based Care
Using formalized teams to increase
collaboration of care
Alternative Encounters
Providing opportunities outside of the face-to-
face encounter for relationship
Cross-Consortium Coordination
Managing across sites and settings to improve
care continuity
Patient Education
Teaching patients about their disease
Outreach/Case Management
Tracking patients and their status
proactively
Decision Support At the Point of Care
Translating disease management
guidelines to patients-specific
recommendations for clinicians.
Guidelines/Protocol
Providing information to clinicians on
recommended clinical management
Performance Feedback
Measuring performance in delivering
desired care and achieving improved
outcomes

42. Lifestyle interventions
Low risk At risk
Disease
Management
DiseaseSymptomsEarly Signs
Preventive Services Case Management
Screening
Primary and Secondary
Prevention
Acute
treatment
Disease
Management
HEALTH IMPROVEMENT
DISEASE MANAGEMENT
HEALTH MANAGEMENT
POPULATION-BASED CASE-BASED

43.  Primary care dominated by chronic illness care
 Clinical and behavioral management increasingly
effective BUT increasingly complex
 Inadequate reimbursement and greater demand
forcing primary care to increase throughput—the
hamster wheel
 Unhappy primary care clinicians leaving practice;
trainees choosing other specialties
 Loss of confidence in primary care by policy-makers
and funders
 But, there are new models of primary care and
growing interest in changing physician payment to
encourage and reward quality

44. World Health Report: 2008

45.  Coordinate with other partners - central
government + local authority + community
+ private sector,
 Working in community – home ward,
 Proactive, outreach services based on
community health needs,
 Care coordination – horizontal and vertical
levels and case management system

46.  A “continuous healing relationship” with a care team
and practice system organized to meet their needs
for:
 EffectiveTreatment (clinical, behavioral, supportive),
 Information and support for their self-management,
 Systematic follow-up and assessment tailored to clinical
severity,
 More intensive management for those not meeting targets,
and
 Coordination of care across settings and professionals

47. Reviews of interventions in other
conditions show that practice changes
are similar across conditions
Integrated changes with components
directed at:
use of non-physician team members,
planned encounters,
modern self-management support,
Intensification of treatment
care management for high risk patients
electronic registries

48. Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
PracticeTeam
Improved Outcomes
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model

49. Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team

50. Assessment of self-management goal attainment and
confidence as well as clinical status
Adherence to guidelines
Tailoring of clinical management by stepped protocol (Treat to
target)
Collaborative goal-setting and problem-solving resulting in a
shared care plan
Planning for active, sustained follow-up
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
How would I recognize a
productive interaction?

51. Informed,
Activated
Patient
They have goals and a plan to improve their health,
and the motivation, information, skills, and confidence
necessary to manage their illness well.

52. Goal
To help patients take a more active role and be
more competent managers of their health and
healthcare.

53. Goal
To help patients access effective and useful services
and resources in the surrounding community.

54. Prepared
Practice
Team
Practice team and interactions with patients
organized to help patients reach clinical targets
and self-management goals.
.

55. Goal
To organize practice staff, schedules and other
systems to assure that all patients receive
planned, evidence-based care.

56. Goal
To assure that clinicians and other staff have the
training, scientific information and system
support to routinely provide evidence-based
(adhere to guidelines) and patient-centered
care.

57. Goal
To assure that clinicians and other staff have
ready access to patient information on
individuals and populations to help plan,
deliver and monitor care.

58. Goal
To assure that practices within the organization
have the motivation, support and resources
needed to redesign their care systems.

59.  Practices spent considerable time searching
for/developing tools
 Some practices felt intimidated by taking on the whole
model – asked for a sequence
 Many changes were made in ways that were not
sustainable logistically or financially (e.g., double data
entry)
 CCM elements implemented as “special events” rather
than part of routine care
 Many achieve process improvements but outcomes don’t
change

60. Self-Management Support
and Community Resources

61. Community, Environment, Policy
Systems, Organizations, Businesses
Family, Friends
Peer Groups
Individual

63. Self-Management
Support
Delivery
System
Design
Decision
Support
Clinical
Information
System
Health System
Organization of Health Care
Community
Resource and Policies
Informed,
Activated Patient
Prepared,
Proactive
Practice team
Productive
Interaction
Functional and ClinicalOutcomes

64.  Provide reminders for providers and patients.
 Identify relevant patient subpopulations for
proactive care.
 Facilitate individual patient care planning.
 Share information with providers and patients.
 Monitor performance of team and system.

65. Barriers to CIS use
Lack of perceived value
Competing business and productivity
demands
Lack of office flow expertise
Lack of information support
Lack of leadership support

66. Functionality!
Whatever you use should be able to
deliver information that supports:
population planning
clinical summaries at the visit
individual care planning
reminders
performance feedback

67. be organized by patient; not disease, but responsive
to disease populations
contain data relevant to clinical practice
assist with internal and external performance
reporting
guide clinical care first, measurement second!

68. Everyone, including senior leadership understands
the clinical utility and supports the time involved in
upkeep.
Data forms are clear, data entry role is assigned, data
review time allotted.
Data entered and retrieved are clinically relevant, and
used for patient care first, and measurement
second.
Data can be shared with patient to improve
understanding of treatment plan.

70. Investors
Customers
Prospects
Press/Analysts
Partners
Employees
Potential Employees
Influencers
MESSAGES
Competitors

71. No. Rank Country
Number of Facebook
users March 2009
Number of Facebook
users 31st March
2010
12 month growth %
4 8 Philippines 1,026,300 11,561,740 1027%
5 15 India 1,561,000 7,809,800 400%
6 19 Malaysia 1,197,560 5,552,660 364%
7 23 Thailand 284,340 2,895,320 918%
ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร
สำนักงำนปลัดกระทรวงคมนำคม
Facebook usage statistics - March 2010
(with 12 month increase figures)

72.  จานวนผู้ใช้ Facebook ทั่วโลก 465,562,160 คน
 จานวนผู้ใช้ Facebook ในประเทศไทย 3,757,340 คน คิดเป็น
0.81% ของทั่วโลก
Female
2,069,440
55.8%
Male
1,636,040
44.2%
Thailand Male / Female
ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร
สำนักงำนปลัดกระทรวงคมนำคม
Facebook usage statistics - March 2010

73. <= 13 36,220 (1.8%)
14 – 17 271,980 (13.1%)
18 – 24 778,400 (37.6%)
25 – 34 714,840 (34.5%)
35 – 44 189,680 (9.2%)
45 – 54 54,820 (2.6%)
55 – 64 13,660 (0.7%)
65+ 9,780 (0.5%)
Thailand Age Distribution
ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร
สำนักงำนปลัดกระทรวงคมนำคม
Facebook usage statistics - March 2010

74.  18 file and OPD
individual record
 HCIS , JHCIS, HosXP,
etc.
 Report for claim
 New media , Social
network
 Tele consultation

75.  Blogs
 Wikis
 Facebook , twitter
 Podcasts
 Videocasts /Vlogs
 Moblogs
 MMS
 Internet telephony i.e.
skype™
Tools that facilitate:
 Communication
 Engagement
 Transparency
 Trust
Tools that are:
 Complementary to
traditional communication
activities
 Used by organizations who
recognize the social
characteristics of effective
communication

77.  Asymptomatic Screenings
 Lifestyle Modifications
 Cessation of Addictive Behaviors
 Medical Regimen Compliance
 PrecautionAdoption

78.  Health Information
 Behavior change
 Self-management
 On-line
communities
 Decision support
 Disease
management
 Healthcare tools
Office of Disease Prevention and Health Promotion, DHHS. Expanding the Reach and Impact of
Consumer e -HealthTools. 2006.

79.  Improve dietary habits
 Increase physical activity levels
 Reduce heavy drinking
 Decrease disordered eating behaviors
 Improve adherence to treatment protocols
 Impact on health care utilization and costs?
Office of Disease Prevention and Health Promotion, DHHS. Expanding
the Reach and Impact of Consumer e -HealthTools. 2006.

80.  The appropriate model for obesity and
weight management is tailored information
according to design principles suggested by
Social CognitiveTheory and the Social
Marketing Model.
 The health behaviors to target are self-
monitoring of diet and physical activity.
 The devices areWeb-enabled “smart” cellular
telephones and wireless PDAs.
JTTufano & BT Karras. Mobile eHealth Interventions for Obesity:
ATimely Opportunity to Leverage ConvergenceTrends. Journal
of Internet Medical Research 2005;7(5):e58).

81. ลาดับเตียงผู้ป่วย
ฟอร์มในการลงข้อมูล
หน้าต่างฟอร์มต่างๆ
ข้อมูลผู้ป่วย

82.  Embed evidence-based guidelines into
daily clinical practice.
 Integrate specialist expertise and primary
care.
 Use proven provider education methods.
 Share guidelines and information with
patients.

83.  Evidence-based medicine is an approach to
health care that promotes the collection,
interpretation, and integration of valid,
important and applicable evidence.
 The best available evidence, moderated by
patient circumstances and preferences, is
applied to improve the quality of clinical
judgments.
McMaster University

84.  Customize guidelines to your setting
 Embed in practice: able to influence real time
decision-making
Flow sheets with prompts
Decision rules in EMR
Share with patient
Reminders in registry
Standing orders
 Have data to monitor care

85.  Often begins with lifestyle change or
adaptation (eliminate triggers, lose
weight, exercise more)
 First choice medication
 Either increase dose or add second
medication, and so on
 Includes referral guideline

86.  Shared care agreements
 Alternating primary-specialty visits
 Joint visits
 Roving expert teams
 On-call specialist
 Via nurse case manager

87. Interactive, sequential opportunities in small
groups or individual training
 Academic detailing
 Problem-based learning
 Modeling (joint visits)

88.  Build knowledge over time
 Include all clinic staff
 Involve changing practice, not just acquiring
knowledge
Evans et al, Pediatrics 1997;99:157

89. Principles of CIS &DS

90. PBGH Evaluation of Consumer Decision SupportTools June 2007

91.  Stoplight tools
 Expectations for care
 Wallet cards
 Web sites
 Workbooks

92. Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
PracticeTeam
Improved Outcomes
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model

93.  Workforce Development
 Up front training and Admin Support
 Professional development
 Integration of Complementary Medicine
 Micro system optimization

94.  Clinical
 Doctor,
 Nurse Case Manager
 Support groups
 Behavorist
 Pharmacist, Nutrition, H. Ed.

95. Demand
* Complex
health problem
*Explosion of knowledge
and technology
*Health care reform
*Expand the scope of
nursing
Supply
*Shortage of health
care personnel, both
quantity and quality
*Malutilization especially
nurse
Unsafe both nurses and patients/clients