摘要多学科联合慢病管理模式是一种新型疾病照护模式,目前在慢性肾脏病专科领域中较为广泛应用,但在临床实践中仍存在多种问题,如缺乏系统、具体的运行规范等.本文对多学科联合照护模式在我国慢性肾脏病患者管理中的实践经验进行梳理和总结,阐述了多学科联合照护模式的概念、在慢性肾脏病患者管理中的人员组成及分工、具体运行模式、干预方式、临床应用效果及存在问题,为多学科联合照护慢性肾脏病管理模式在慢性肾脏病个案连续性照护中的应用提供参考.

abstractsMultidisciplinary cooperation (MDC) chronic disease management model is a new care model, which is widely used in the specialty area of chronic kidney disease. However, there are still many problems in clinical practice, such as the lack of systematic and specific operating instructions. In this paper, we reviewed and summarized the practices of MDC in chronic kidney disease management in China. We also explained the concept of the MDC, composition, and division of labor in chronic kidney disease management, the specific operating model, intervention methods, clinical effects, and existing problems. This review provided references for the application of MDC in continuous care of chronic kidney disease cases management.