損保ジャパン記念財団叢書 №៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅ฌᦠ  0Q៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅ฌᦠ 0Q‫࠻ࡦࡔࠫࡀࡑ࡮࠭࡯ࠫࠖ࠺ޟ‬᡽╷⺖㗴⎇ⓥળ‫ޠ‬ႎ๔ᦠ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻ߦ㑐ߔࠆ᡽╷ߩ࿖㓙Ყセ﹁ディジーズ・マネジメント政策課題研究会﹂報告書 ディジーズ・マネジメントに関する政策の国際比較

82‫࠻ࡦࡔࠫࡀࡑ࡮࠭࡯ࠫࠖ࠺ޟ‬᡽╷⺖㗴⎇ⓥળ‫ޠ‬ႎ๔ᦠ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻ߦ㑐ߔࠆ᡽╷ߩ࿖㓙Ყセ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻᡽╷⺖㗴⎇ⓥળᐳ㐳 ↰ਛ ṑ㧔ᘮᔕ⟵Ⴖᄢቇᄢቇ㒮ᢎ᝼㧕







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公益財団法人損保ジャパン記念財団

 ⊒ⴕᣣ  ᐔᚑ㧞㧠ᐕ㧟᦬㧟㧜ᣣᐔᚑ㧞㧠ᐕ㧟᦬౏⋉⽷࿅ᴺੱ ៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅࿒ষ
͉̲͛ͅ! ȪP2 -P4ȫ
ల 1 ડ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͈࿚ఴȂે‫ޙ‬ȪP5-P17ȫల 1 ୯! ৖ພࢹ௮͈་‫͂ا‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ
ల 2 ୯! ဥࢊȆဥ༹͈ାၑ̤͍৾ͤ͢ષ̬ͥํս
ల 3 ୯! ༀ࣭̤̫ͥͅΟͻΐȜΒȆζΥΐιϋΠ‫ٽ‬ැ͈೹մȆ৘க͂ଲ‫ٮ‬എ෨‫ݞ‬
ల 4 ୯! ΟͻΐȜΒȆζΥΐιϋΠ͈ဥ༹͈ఉ݅଻ུ͂༭࣬੥͈೰݅Ȇဥ༹
ల 5 ୯! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫͂ض‬໅౜
ల 6 ୯! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈අ଻͂ఉအ଻
ల 7 ୯! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθଽॐ͈൚ম৪͂ࢹ଼ါள
ల 8 ୯! ΰσΑΉͺΏΑΞθ͈අಭ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔ༹༷ల 9 ୯! ଽহࠐफഎ̈́ଽॐࠁ଼ജ‫ٳ‬
లˎડ! ‫͈࣭ڎ‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ(P18-P65)
ల 1 ୯! ‫଼ࢹ͈੆ܱ͈࣭ڎ‬Ȇ໦ଢ଼ণ‫!ڙ‬
ల 2 ୯! ༀ࣭ల 3 ୯! ΂ȜΑΠρςͺ
ల 4 ୯! Ώϋ΄εȜσల 5 ୯! ‫࣭ם‬
ల 6 ୯! ΃΢Θల 7 ୯! ΡͼΜల 8 ୯! ‫࣭܀‬
లˏડ! ‫࣭ڎ‬๤‫̥ͣڛ‬ංͣͦͥাऐ(P66-P72)
ల 1 ୯! ୶ૺ‫͈࣭ڎ‬ଽॐ৘ঔ͈აത͂ଽॐ৘࣐ͅ‫ه̳ͥ۾‬ఴ
ల 2 ୯! ඾ུ͈අ೰࠲૷Ȇඅ೰༗࠲ঐ൵মު͈අಭ͂ଽॐ‫ه‬ఴΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬͈ٛࡄ‫ڰݪ‬൲(P73-P74)-1-ߪߓ߼ߦ
ɃΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬ٛɄΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬͉ٛȂ2005 ාఅ༗ΐλΩϋܱැ़౬৽ट͈ࡄ‫ݪ‬̱ٛ͂̀୭౾̯̹ͦȃ2006 ා 1 ࠮͉ͅȂ࣭षΏϋεΐ;θȶ̭̥͈ͦͣ୆‫ڰ‬ਠ‫۝‬ພచॐ͈̜༷ͤͬౝͥȽༀ࣭͈ιΟͻΉͺȂιΟͻΉͼΡ̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ൵ව̥ͣ‫͐ڠ‬ȷͬ‫ٳ‬ट̱̹ȃ2008 ාഽո͉ࣛȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͈࣭ष๤‫ݪࡄͬڛ‬ΞȜζ̱͂̀Ȃࡄ‫ݪ‬ٛ‫ڰ‬൲ͬࠑ௽̧̱̹̀Ȫࡄ‫ݪ‬͈ٛտ֥̤͍͢‫ڰ‬൲‫ٽ‬ါ͉‫͈ྎے‬ȶΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬͈ٛࡄ‫ڰݪ‬൲ȷ४ચȫȃΟͻΐȜΒȆζΥΐιϋΠ̤͍͢ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̞̠͂ဥࢊ͉ͅȂ̷͈ဥࢊͬঀဥ̳ͥ൚ম৪̽̀͢ͅ։̈́ͥփྙࣣ̞Ȃփ݅ͬဓ̢̞࡛ͣͦ̀ͥે̜ͥͅȃ‫ڎ‬൚ম৪͉Ȃ̷͈΋ͺ̜ͥͅࣉ̢༷Ȇอே͉‫ވ‬ခ̱͉̞̦̀ͥȂຈ̴̱͜ൡ֚എͅਓᓦ̱
̞̀ͥփ̷͈݅́ဥࢊͬঀ̞̽̀ͥે‫̞͉̈́ͅޙ‬ȃུࡄ‫ݪ‬͉ٛȂ̷͈ે‫ࣉͬޙ‬ၪ̱̀Ȃဥࢊ͈փ̞͉݅̾̀ͅࡄ‫ݪ‬࿒എͅ؊̲̀਴඲ͅࣉ̢̀Ȃࡄ‫̧̹̀͛ૺͬݪ‬ȃུ༭࣬੥͉Ȃ඾ུ̤̫ͥͅඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵ͅ‫̳ͥ۾‬ଽॐ࣭ͬषഎͅ๤‫̳ͥڛ‬۷ത̥ͣȂΟͻΐȜΒȆζΥΐιϋΠ̤͍͢ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ဥࢊͬ೰̱݅̀ဥ̞ͥȃɃྕ଻৖ۛ൝͈࿚ఴ৾ͤͅழ͚̹͈͛ίυΈρθɄ୶ ૺ ࣭ ́ ͉ Ȃ ۜ அ છ (communicable disease) ̥ ͣ ྕ ଻ ৖ ۛ Ȇ ୆ ‫ ڰ‬ਠ ‫ ۝‬ພ(non-communicable disease, chronic disease) ͈͒৖ພࢹ௮͈་‫ا‬ȂࣞႢ‫ا‬Ȃ̷ฺ̠ͦͅ
֓ၷఘଷ͈๱࢘ၚ଻Ȃ֓ၷ๯͈ષઌ͈̈́̓‫ވ‬೒࿚ఴͅೄ࿂̱Ȃ̷͈చ؊ॐͬ৘ঔ̱̞̀ͥȃ̷͈చ؊ॐ͈۪̱֚͂̀Ȃ‫͉࣭́ڎ‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦൵ව̯̞ͦ̀
ͥȃ̭͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃྕ଻৖͈ۛ࿚ఴ৾ͤͅழ͚̹͈͛ခႁ̈́
ίυΈρθ̜͈́ͥ͂฻౯̥ͣȂ֓ၷ༗ࡏ৪̦֓ၷ༗ࡏ͈‫ح‬ව৪ͬచય̱͂̀Ȃ౷༷ଽຸ͉౷֖͈ਯྦྷ̈́̓ͬచય̱͂̀Ȃༀ࣭͉̲ͬ͛୶ૺ‫̩ࢩ࣭́ڎ‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦৘ঔ̧̯̞ͦ̀̀ͥȃɃ৖ພထཡ঑‫͈׳‬ίυΈρθɄΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃࡢ૽ͅ൲‫̞࣐̫ͬັܥ‬Ȃ࠲ࢫςΑ·ͬ೩ࡘ̳ͥίυΈρθ̜́ͥȃ৽̱͂̀ྕ଻৖ۛͅ‫̦૽ࡢ̱̀۾‬৖ພထཡ͈࣐൲ͬ঵௽̱࠲ࢫςΑ·ͬ೩ࡘ̳̭ͥ͂ͬ঑‫̳ͥ׳‬ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ৖ພထཡ঑‫͈׳‬ίυΈρθ̜́ͥȃ-2-Ƀ࣭ष๤‫͈ڛ‬փྙɄ̷̸͈࣭͈ͦͦΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃࡢ૽ͅ൲‫ࢫ࠲̞࣐̫ͬັܥ‬ς
Α·ͬ೩ࡘ̳͈ͥ͂‫ވ‬೒͈࿒ດͬ৘࡛̱̠͂͢৘ঔ̯̞͈ͦ̀ͥ͜ͅࢰ̴ͩͣȂఉအ̈́ࠁఠ̞ͬ৾̽̀ͥȃίυΈρθ̦చય̳͂ͥ৖ພȆႀ֖͉Ȃ֚ষထཡ̥ͣඅ೰͈৖ພ͈ਹછ
‫ا‬ထཡ́͘အș̜́ͥȃ̹͘Ȃ̷͈౜̞਀͜Ȃఉਅ͈֓ၷ୺࿝૖Ȫ֓঍Ȃۭࢌ঍Ȃ‫ူו‬আ̈́̓ȫͬྦྷ‫ۼ‬মު৪̦৽ఘ͂̈́̽̀ழ૕‫̳ͥا‬κΟσȂ֓঍ͬಎ૤̳͂ͥκΟσ̈́̓ఉအ̈́ࠁఠ̞ͬ৾̽̀ͥȃ̷͈ఉအ଻͉Ȃ̷̸͈࣭̤̫ͦͦͥ֓ͅၷͅ‫۾‬Ⴒ̳ͥ։̈́ͥଷഽȂ঩࡙ͅဇြ̱Ȃ̯ͣͅอജࠐ֌ͅࠐႹջం଻̦̜̹ͥ͛୆̲̞̀ͥȃ̷̸͈࣭͉ͦͦ́Ȃ৽̱͂̀ྕ଻৖͈ۛ࿚ఴ৾ͤͅழ͚̹͛ͅΟͻΐȜΒζΥΐιϋ
ΠȆίυΈρθͬ৘ঔ̳ͥଽॐ̦ജ‫̞̯ͥ̀ͦٳ‬ȃ඾ུ̤̞͉̀ͅ 2006 ා̥̳͓͈ͣ̀֓
ၷ༗ࡏ৪̦අ೰࠲૷Ȇඅ೰༗࠲ঐ൵মުͬ৘ঔ̳ͥ݅ྩͬ໅༹̠ၙ̦ঔ࣐̯̹ͦȃ඾ུ͈අ೰࠲૷Ȇඅ೰༗࠲ঐ൵মު́৘ঔ̯ͦͥίυΈρθ͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̧ٜ̳̭̦͂ͥ͂́ͥȃ඾ུ͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̳͓͈ͬ̀֓ၷ༗ࡏ৪̦৘ঔ̳ͥଽॐͬ
ജ‫̞̱ͥ̀ٳ‬ȃ୶ૺ‫̞̤࣭̀ͅڎ‬Ȃ඾ུ͂൳̲ম႕͉ࡉ̜̹̞ͣ̈́ȃ̷̸͈࣭͉ͦͦȂ̷͈࣭͈Ȃ̷͈শయ͈࿚ఴٜࠨͬ࿒ঐ̱̀Ȃඊু͈ଽॐͬജ‫̳ͥٳ‬ȃ‫࣭ڎ‬༆ͅ௖֑͉̜ͥ͜
͈͈Ȃ̷͈ଽॐ͉ͅ৽̱͂̀ྕ଻৖͈ۛ࿚ఴ৾ͤͅழ͚̹͛ͅଽॐ̦ജ‫̭̞̯͂ͥ̀ͦٳ‬Ȃ̤͍͢ྕ଻৖ۛͅచੜ̳̹͈ͥ͛ίυΈρθ̦࢘‫͉̬̜ͥͬͅض‬ຈါ̯͂ͦͥȂ‫ވ‬೒͈ࢹ଼ါளȆι΃ΣΒθ̦̜̭̥ͥ͂ͣȂଽॐജ‫ވ͉ͅٳ‬೒଻̜ͥ͜ȃ‫ུܖ‬എষࡓ͈́‫ވ‬೒଻࣭͂༆͈௖֑͉Ȃ̷͈๤‫̀̽͢ͅڛ‬ခ‫̈́ף‬াऐͬංͥ‫خ‬ෝ଻ͬဓ̢̞̀ͥȃ࣭ष๤‫͉ڛ‬Ȃඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵মުͅ‫̳ͥ۾‬ଽॐജ‫̞̀̾ͅٳ‬Ȃࣽࢃ͈ͤ͢৘கഎ࢘‫ض‬എͅ৘ঔ̳̹ͥ͛ͅࣉၪ̧̳͓‫ه‬ఴͬࣉ̢ͥ४ࣉ͂̈́ͥȃ̭͈࠿൦ͬ೒̱
̀Ȃ඾ུ̤̞̀ͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬอജ̵̯ͥ‫ܖ‬๕ା๵ͅ‫̱ࣽ̀۾‬ࢃ৾ͤழ̧͚͓‫ه‬ఴ͈ྶ‫ܢ̦اږ‬ఞ̧́ͥȃɃ༭࣬੥͈ࢹ଼Ʉ
ུ༭࣬੥͉Ȃࡄ‫ݪ‬̧̤̞࣐̹ٛ̀̽̀ͅȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳۾‬ͥଽॐ͈࣭ष๤‫࠿̳ͥ۾ͅڛ‬൦ࠫ‫̜͈̹ͥ́͛͂ͤ͂ͬ͘͜ض‬ȃུ༭࣬੥͉Ȃ3 ડࢹ଼͂̈́
̞̽̀ͥȃ̴͘Ȃల 1 ડ̤̞̀ͅྕ଻৖͈ۛ࿚ఴͅచ̱̀৖ພထཡ঑‫׳‬ίυΈρθ̜́ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬଽॐഎͅജ‫࣭͈ޙે̳ͥٳ‬ष๤‫̹̠࣐͛ͬͅڛ‬ຈါ̯͂ͦ
ͥমࣜͬାၑ̱̹ȃల 2 ડ͉Ȃ඾ུ͂‫ވ‬೒଻ͬခ̳ͥȂ୶ૺ‫͈࣭ڎ‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐജ‫ٽͬٳ‬۷̱̹ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐͅ‫̳ͥ۾‬෸ࠊȂ‫ڟ״‬Ȃଽॐ‫ه‬ఴ̞͈̾̀ͅૂ༭ͬାၑ̱̹ȃల 3 ડ͉Ȃ඾ུ͈අ೰࠲૷Ȇඅ೰༗࠲ঐ൵͂‫͈࣭ڎ‬๤‫̥ͣڛ‬ංͣͦͥȂଽॐ‫ه‬ఴͅ‫̳۾‬-3-ͥাऐͬ࠿൦̱̹ȃ̤̈́Ȃ൳͈֚ౙࢊ̷̸͈࣭́ͦͦ́͜৹ۙ௖֑̳ͥփྙ́ဥ̞̞̭̦̜ͣͦ̀ͥ͂ͥȃ̹͘Ȃ඾ུ̤̞̀ͅ΃Η΃΢̱͂̀ဥ̞̞ͣͦ̀ͥဥࢊ͜൚‫͉࣭́ڂ‬։̈́ͥփྙࣣ̞ͬ঵
̭̜̾͂ͥ͜ȃ̭͈̹͛Ȃུ༭࣬੥͉́Ȃຈါ͂̈́ͥાࣣ͉ͅࢋ෇ͬ๰̫̹ͥ͛ͅࡔࢊ̷
͈́͘͘ဥ̞̞̀ͥ‫ؿ‬ਫ਼̦̜̭̤ͥ͂ͬ౯̳ͤͥȃ-4-╙  ┨ ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߦ㑐ߔࠆ᡽╷ߩ໧㗴⁁ᴫΟͻΐȜΒȆζΥΐιϋΠ̤͍͢ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈̈́̓ဥࢊ͉Ȃ‫̞̤࣭̀ͅڎ‬ຈ̴̱͜ൡ̯̞̞֚ͦ̀̈́ȃ̹͘ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ̷̸̷͈࣭̤̞͈࣭͈ͦͦ̀ͅ২ٛഎ໲ྤ̤͍͢อജࠐ֌͈̥̈́́৘ঔ̯͈ͦͥ́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͜২ٛഎ໲ྤ̤͍͢อജࠐ֌ͅ‫̯ͥͦޣג‬࿂̦‫̞ޑ‬ȃܰ࿅̦ఱ̧̞చયਬ౬ͅచ̱̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥ࢖എ̈́ଽॐ̱͂̀ജ‫̯ͥͦٳ‬ાࣣ͉ͅȂଽॐ৘ঔ͈ࢹ଼ါளͬାၑ̱̀ၑٜ̳ͥຈါ̦
̜ͥȃུડ͉́Ȃఉ݅എ̈́ΟͻΐȜΒȆζΥΐιϋΠȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθȂଽॐ͈̈́̓‫ུܖ‬എ̈́ဥࢊȆဥ༹ͬାၑ̱ȂΟͻΐȜΒȆζΥΐιϋΠ̦ଲ‫ٮ‬എͅຽ‫ٽًͬࠐ̹̞̱̽̀ݞ‬۷̱Ȃ࢖എ̈́ଽॐജ‫͈ٳ‬ष͈ࢹ଼ါளͬ࠿൦̱ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͈࣭ष๤‫͈̹̳͛ͥͬڛ‬იழͬ೹া̳ͥȃల 2 ડ̤͍͢
ల 3 ડ̤̫ͥͅȂ๤‫ڛ‬໦ଢ଼ͬယօܑ̳̭ͥ͂ͬͅ଎̱̞̀ͥȃ╙  ▵ ∔∛᭴ㅧߩᄌൻߣ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓ
୶ૺ࣭‫ވ‬೒ͅȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅచ̳ͥ‫۾‬૤̦ࣞͤ͘ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬଽॐഎ৾ͤͅષ̬৘࣐̱̠̳͂ͥ͢෸ࠊ̱͂̀Ȃ૽࢛͈ࣞႢ‫̥̳࣐̈́ͥૺ̦ا‬Ȃ৖͈ۛਹ૤̦‫͈ܢ଻ݢ‬৖̥ۛͣྕ଻‫͈ܢ‬৖ۛ͒ΏέΠ̱̹̞̠͂৖
ພࢹ௮͈་‫̜̦ͥا‬ȃྕ଻৖͈ۛ͒ΏέΠ͉ȂࣞႢ‫ ͉̀̽͂ͅ૽ࡢ̞̱ͥ̀ا‬QOL ͈೩‫̱̹ͣͬ͜ئ‬Ȃ़ଽഎ͉֓ͅၷ঑੄௩‫़ͥ͢ͅح‬ଽ໅౜Ȇ༗ࡏ‫͈ັݯ‬௩ఱ̹̱̞ͬͣ̀ͥ͜ȃ̭͈ͦͣ࿚ఴͅచ
ੜ༹̳༷̱ͥ͂̀Ȃ࢘‫ض‬എ̈́ထཡ৾ͤͅழ͚̭̦͂ࢩ̩৘࣐̯̞ͦ̀ͥȃ̷ͦ̽̀͢ͅȂ
QOL ͈೩‫ͬئ‬۱გ̱Ȃ़ଽ໅౜ͬࠚࡘ̳̭̦ͥ͂‫ܢ‬ఞ̯̞ͦ̀ͥȃΟͻΐȜΒζΥΐιϋ
ΠȆίυΈρθ͉Ȃခႁ̈́৖ພထཡ঑‫׳‬ίυΈρθ͈̜͌͂̾́ͥȃྕ଻৖ۛͅచ̳ͥထཡ‫ڰ‬൲͉Ȃౣ‫ܢ‬എ͉ͅȂ႕̢͊Ȃ૽ࢥ൫ଢ଼ۛ৪ତȂ௩՛ͬ߫ͤ༐̳
૤ະ஠͈ව֭ۛ৪ତ͈ࡘઁͬ৘̧࡛̳̭̦ͥ͂́Ȃ़ଽ໅౜͈ࠚࡘͬ৘̧࡛́ͥȃਲ̽̀Ȃྕ଻৖͈ۛ৖ພထཡίυΈρθ͉Ȃଽॐഎࡉ౷̥̳ͣͥ͂ȂQOL ͈೩‫͈ئ‬۱გ़͂ଽ໅౜
͈ࠚࡘ̥ͣȂ‫۾‬૤̩̭ͬ֨͂̈́ͥͅȃ! ထཡ֓‫͉́ڠ‬Ȃထཡͬ 3 ̾ͅ໦̫̞̀ͥȃ̳̻̈́ͩȂ֚ষထཡ(࠲ࢫ։ુ̦੄࡛̳ͥஜ͈Ȃ࠲ࢫ௩ૺ‫ڰ‬൲Ȃ৖ພςΑ·೩ࡘ‫ڰ‬൲ȫȂඵষထཡ(࠲ࢫ։ુ̦੄࡛̱̥̀ͣ৖ພ଼̱̳͂̀ۖ
͈ͥ́͘‫͈ۼ‬Ȃ்‫ܢ‬อࡉȂ்‫ܢ‬হၷȫȂ२ষထཡ(৖ພ଼̱̱̹͂̀ۖࢃ͈ȂςΧΫςΞȜΏοϋȂठอཡগ)̜́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ̭͈ͦͣထཡ͈֚໐͘

-5-̹͉஠໐ͬ৘࡛̱̠̳͂ͥ͢ίυΈρθ̜́ͥȃਲ̽̀Ȃ࿒ດȂచયਬ౬̽̀͢ͅထཡ͈
̜༷̦ͤ։̭̈́ͥ͂ͬ฽‫̱̀ד‬Ȃఉအ̈́ίυΈρθ̦ంह̳̭ͥ͂̈́ͥͅȃ╙  ▵ ↪⺆࡮↪ᴺߩᢛℂ߅ࠃ߮ขࠅ਄ߍࠆ▸࿐! ུ୯͉́Ȃུ༭࣬੥́ဥ̞ͥ‫ུܖ‬എ̈́ဥࢊȆဥ༹̞̾̀ͅାၑ̳ͥȃ‫ུܖ‬എ̈́ဥࢊ̱͂
͉̀ȂӱଽॐȂӲίυΈρθ̜́ͥȃΟͻΐȜΒȆζΥΐιϋΠ͜‫ུܖ‬എ̈́ဥࢊ̜̦́ͥȂల 4 ୯́મა̳ͥȃଽॐ͉Ȃ࢖എ̈́ழ૕̺̫̦౜̠͉͂ࣉ̢̞̈́ȃଽॐ͉࢖എ̈́ழ૕̜́ͥଽຸȆଽൂ̈́̓̽̀͢ͅ৘࣐̯ͦͥȂ২ٛഎ̈́࿚ఴٜͬࠨ̳༷ͥॐȆْࠗȂ̤͍͢জഎ̈́ழ૕ͥ͢ͅ࿒ດ
ో଼༹͈̹͈༷͛Ȇْࠗ͂௴̢ͥȃ࢖എ̈́ଽॐ͈༷ॐ̱͉͂̀Ȃুͣထॳͬ঵̽̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৏࣐̳ͥո‫ͅٸ‬Ȃ༞੩߄‫ັݯ‬Ȃ̤͍͢ૂ༭೹‫ͥ͢ͅރ‬௯ૺ̦̜̬̈́̓ͣͦͥȃজഎ̈́ழ૕ͥ͢ͅଽॐ̱͉͂̀Ȃ֓ၷ༗ࡏ৪̦Ȃ‫ح‬ව৪ͅచ̱̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬুࡨ͈๯ဥ́೹‫̬̜̦̭̳ͥͦͣ̓̈́͂ͥރ‬ȃίυΈρθ͉Ȃൢో̧̳͓࿒ດͬ৘࡛̳̹͈ͥ͛‫ڰ‬൲ْ̞̠ࠗͬȃΟͻΐȜΒζΥΐι
ϋΠȆίυΈρθ͉ͅȂඵ͈̾ਅ႒̦̜ͥ͂ࣉ̢ͥȃ̳̻̈́ͩȂࡢ૽ͅచ̱̀঑‫̹͈͛׳‬ٚͅව̳ͥȶࡢ૽̫࢜ίυΈρθȷȂ̜ͥঐດͬ‫ܖ‬੔̱͂̀ਬ౬͈࠲ࢫςΑ·ͬ٨஝̳ͥȶਬ౬̫࢜ίυΈρθȷ̦̜ͥȃུ༭࣬੥͉́Ȃࡢ૽͂ਬ౬͂ͬߊ༆̳ͥຈါ̦̜ͥાࣣͅȂȶࡢ૽̫࢜ίυΈρθȷ̹͉͘ȶਬ౬̫࢜ίυΈρθȷ͂ઠ̳ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͉Ȃ‫̳ͥ߸۾‬൚ম৪ͅ൲‫̞࣐̫ͬັܥ‬ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦৘ْ࣐̯̠̱ͦͥࠗ͢ͅ‫̠̞̭̳ͬ͂ͥא׋‬ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͉Ȃ৽̱͂̀ྕ଻৖͈ۛۛ৪̤͍͢
̷͈ထ๵߲ͅచ̱̀ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘̵࣐̯Ȃ࢘‫̭̬̜ͥͬض‬͂ͬ࿒ດ̳͂ͥଽॐ̞̠ͬȃུ༭࣬੥͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐͬ࠿൦̳ͥȃ৾ͤષ̬ͥํս͉ଽॐͅ‫̦̭̳͂ͥ۾‬ಎ૤̜͈́ͥ́Ȃࡢ༆͈ίυΈρθ͈મळ͉ͅၛ̻ව̞ͣ̈́ȃ╙  ▵ ☨࿖ߦ߅ߌࠆ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻᭎ᔨߩឭ᩺࡮ታ〣ߣ਎⇇⊛ᵄ෸ྕ଻৖͈ۛ৖ພထཡίυΈρθ͈‫ٳ‬อ৘ঔ̷͈͂ຽ‫̧̹̦ܳݞ‬෸ࠊ͉ͅȂྕ଻৖̦ۛଽ
ॐષఱ̧̈́‫ه‬ఴ̹̭̦̜̈́̽͂ͥͅȃྕ଻৖ۛͅ‫̳ͥ۾‬৖ພထཡίυΈρθ͈యນ႕͈͌
̦͂̾Ȃ1990 ාయͅༀ࣭́อജ̱̹ΟͻΐȜΒȆζΥΐιϋΠ̜́ͥȃ̭͈ΟͻΐȜΒȆζΥΐιϋΠ͈΋ϋΓίΠ͂৘க͉Ȃༀ࣭́‫ޟ‬ၦ̱̹̺̫̩́̈́Ȃఈ͈࣭șͅ‫ͬޣג‬ဓ̢൵ව̯̞̹ͦ̀̽ȃΟͻΐȜΒȆζΥΐιϋΠ͈ͺίυȜΙ͉Ȃ1980 ාయͅ৘ঔ̯̹ͦȃΟͻΐȜΒȆζΥΐιϋΠ͉Ȃ֓ၷ΍ȜΫΑίυΨͼΘȜ̜́ͥ Mayo Clinic ́‫ٳ‬ই̯ͦȂ1990 ාయͅ Mayo
Clinic ̦֓ၷ༗ࡏ৪̜́ͥ John Deere’s Health Plan ͂ࠁ଼̱̹ΩȜΠ΢ȜΏΛίͅஸͥ-6-͈͂ࡉ༷̦̜ͥ1ȃ̷͈ࢃༀ࣭̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈อജ͉Ȃ΋ζȜΏλσαȜΆૺ͛ͣͦḀ̑̾֓ၷ༗ࡏ৪̦ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬनဥ̱̞̹̭̦̀̽͂ఱ̧̈́ଔૺႁ̹̈́̽ͅȃ̱̥̱Ȃຽ‫ڐݞ‬ఱ͈ই͉ͤ͘Ȃୋ࿪ު‫̥ٮ‬̜̹ͣ́̽ȃ1990 ාయ͈੝͛Ȃༀ࣭͈ୋ࿪ު‫͉ٮ‬ȂΐͿΥςΛ·֓࿪຦Ȃ಺सੜ༷ਬ͈ജ
‫ুͤ͢ͅٳ‬২͈ୋ຦͂ఈ২͈ୋ຦͈ओ։̦ઁ̩̹̈́̈́̽ȃ̭͈̹͛Ȃୋ຦‫̦ڒث‬೩‫̳ͥئ‬༷֚Ȃࡔऺၳࣞ൯ͥ͢ͅ၌‫ף‬ၚ͈೩‫࣪ͬئ‬໚̱̫̞̞̠̈́ͦ͊̈́ͣ̈́͂‫ه‬ఴͅೄ࿂̱̞̀
̹ȃୋ࿪ٛ২͉Ȃࡺ‫ث͈ݖ‬౵஻௮ͬ৘̧࡛́ͥমުκΟσͬ‫̹̞̀͛ݥ‬ȃ1993 ාͅࠐ‫א‬΋ϋ΍σΗϋΠٛ২̜́ͥ Boston Consulting Group ২̦ୋ࿪ު‫͈ٮ‬݈ٛ́೹մ̱̹ΟͻΐȜΒȆζΥΐιϋΠ͈‫ٽ‬ැ2͉Ȃୋ࿪ު‫ه͈ٮ‬ఴ͈ٜࠨͅ঩̳ͥͼΦαȜΏοῧ̱̀਋̫
গ̹͈̜̹͛ͣͦ́̽ȃୋ࿪ٛ২͉Ȃু২ඤͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘࣐̳ͥ໐࿝ͬ୭౾̱Ȃ੭ș଼ͅ‫̹̜̬̜̽̾̾ͬض‬ȃ༷֚Ȃ1995 ා̥ͣ 2000 ා̥̫̀ͅ
ζΥΐΡΉͺͬ৘ঔ̱̞̀ͥ֓ၷ༗ࡏ৪͉ȂζΥΐΡΉͺͅచ̳̱̞ͥࠣ২ٛഎ฽อͅచ
ੜ̱̫̞̞̠̈́ͦ͊̈́ͣ̈́͂‫ه‬ఴͅೄ࿂̱̞̹̀ȃ̷͈‫ه‬ఴٜࠨ͉Ȃအș̈́ါ֦̽̀͢ͅ
ࠫ‫ض‬എͅ୆̲̱̠̀֓͘ၷ΋ΑΠ̦௩‫ે̳ͥح‬ఠͅచ̱̀Ȃ֓ၷ΍ȜΫΑͬဲଷ̳ͥ֓ၷ
๯΋ΑΠॉࡘந౾̥ͣ֓ၷ΋ΑΠ௩‫̜֦ͥ́ࡔ͈ح‬৖ພςΑ·͈೩ࡘͬ࿒ঐ̳৖ພထཡͅ
ΏέΠ̳̭̜̹ͥ͂́̽ȃ̷͈ΏέΠͬ৘̧༹࡛༷̱́ͥ͂̀஖఼̯̹͈̦ͦȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̜̹́̽ȃζΥΐΡΉͺ৘ঔ͈֓ၷ༗ࡏ৪͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ༹̳༷̱ͥ͂̀Ȃুஜ́৘ঔ༹̳༷ͥո‫ٸͅٸ‬໐͒ͺ;ΠΕȜΑ༹̳༷̜̹ͥ̽͜ȃ̷͈൚শΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥ΍ȜΫΑ͈೹‫ރ‬মު৪̦੄࡛̱̞̹̀ȃ̭͈ͦͣমު৪͉Ȃୋ࿪ٛ২̥ͣ໦ၗඊၛ̱̹মު৪
͞႒যުྩ̥ͣૺ੄̧̱̹̀মު৪̜́ͥȃͺ;ΠΕȜΑ୶͈মު৪͉Ȃ֓ၷ๯ॉࡘ࢘‫ض‬ͬ‫̱಺ޑ‬ॉࡘ࢘‫݃ͅض‬࿚ͬ঵̾֓ၷ༗ࡏ৪̷଼͈ͅ‫ͬض‬༗બ̳ͥࠀ࿩༷৆͜մ੄̳̭ͥ͂
ͬ೒̱̀ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥ΍ȜΫΑͬ์ค̱̹ȃ̷͈ࠫ‫ض‬Ȃͺ;ΠΕȜΏϋΈঌા͉‫ڐ‬ఱ̱̞̹̀̽ȃ̭͈̠͢ͅȂୋ࿪ު‫ͼ͈ٮ‬ΦαȜΏοϋ͉Ȃ֓ၷ༗ࡏ৪͈ͼΦαȜΏοϋͅࠒ̦ͤȂ̷̱̀ͺ;ΠΕȜΆ̧ͥঌા଼͜ၛ̱̹͈̜́
ͥȃ1999 ා͉ͅȂༀ࣭̤̞̀ͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬๱‫א‬၌ழ૕
Disease Management Association of America(ո‫ئ‬ȂDMAA ̞̠͂)̦୭ၛ̯̹ͦȃDMAA ͉Ȃ̯̰̈́͘͘‫ڰ‬൲ͬജ‫̦̹̱ٳ‬Ȃ̷͈͉͌͂̾‫ڠ‬ٛধ͈อ࣐̜́ͥȃ̷͈‫ڠ‬ٛধ”Disease Management”͉Ȃ൚শ‫ڰ‬อ‫̹̞̱̀ا‬ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ
͈৘க‫ڰ‬൲͂ࡄ‫ڰݪ‬൲ͬ৾ͤષ̬̹ȃ̷͈ઁ̱ஜ͈ 1997 ා͉ͅΟͻΐȜΒȆζΥΐιϋΠ

Mark Zitter, “A New Paradigm in Health Care Delivery: Disease Management”, inTodd E and David Nash, “Disease Management: A Systems Approach to Improving
Patient Outcomes”,1997. ̹̺̱ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈‫ٳ‬ইশ‫̞̾ͅܢ‬͉̀Ȃ̭͈͕̥͜ͅ։̈́ͥࡉ༷̦̜ͥȃ
2 Boston Consulting Group ২͉ 1995 ා̷͈ͅඤယͬ୰ྶ̱̹໲੥”The Promise of
Disease Management”ͬ࢖ນ̱̹ȃ̭͈໲੥͉ȂStern C and George Stalk eds.,”
Perspectives on Strategy from the Boston Consulting Group”, 1998.ͅਓ჏̯̞ͦ̀ͥȃ1-7-ͅ‫̳ͥ۾‬༆͈࣭षഎ̈́‫ڠ‬ٛধ”Disease Management and Health Outcomes”̦อ‫̯̀ͦۏ‬̞̹ȃༀ࣭͉́ȂΟͻΐȜΒȆζΥΐιϋΠͅ‫ݪࡄ̳ͥ۾‬ਬٛȂ৘க‫ͥ͢ͅز‬Γη΢Ȝ͜‫ڰ‬อ࣐̠̹ͩͦͥ̈́̽͢ͅͅȃ
1990 ාయͅ୆̲̹ༀ࣭͈อജ͈‫ͬޣג‬਋̫̀Ȃ‫࣭ם‬ȂΡͼΜȂ΂ρϋΘ͈̈́̓؎ਗȂ΂ȜΑΠρςͺȂΏϋ΄εȜσȂ඾ུ̈́̓ͺΐͺఊ໹ဢਗ͉́ȂΟͻΐȜΒȆζΥΐιϋΠ
͈‫ٽ‬ැͬ਋̫ව̜̞͉ͦͥ४ચ̳ͥ൲̧̦ࡉ̹ͣͦȃ؎ਗ͉́Ȃ2001 ාͅ WHO ͈‫۾ܥ‬ধͅༀ࣭͈ΟͻΐȜΒȆζΥΐιϋΠ̞̾̀ͅ໦ଢ଼̱Ȃ؎ਗ̤̞̀ͅΟͻΐȜΒζΥΐιϋ
ΠȆίυΈρθͬ൵ව̧́ͥૄ࠯̦̜̭ͥ͂ͬঐഊ̱Ȃ൵වͅ‫̳ͥ۾‬࿚ఴതͬ໦ଢ଼̱̹ა
໲̦࢖ນ̯̹ͦ3ȃ‫͉࣭́ם‬Ȃༀ࣭́อജ̱̹‫ٽ‬ැȆ৘க͉‫̞̤࣭̀͜ͅם‬਱໦ͅ߅ྙ̱̀
൵ව̱̞̩̀‫ث‬౵̦̜͈ͥ͂ଽॐࡄ‫ݪ‬4̦࢖ນ̯̹ͦȃ ̹͘Ȃ‫ ͉࣭́ם‬2002 ා̥ͣ NHS
Modernisation Agency ̦Ȃༀ࣭͈ United Healthcare ২͈ Evercare modelȂ Kaiser
Permanente ͈Medical Care Programme Ȃ Pfizer Health Solutions (PHS) ২ ͈

InformaCare®͈ 3 ͈̾ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ US model ̱͂̀দ࣐൵ව
ͬ৘ঔ̱Ȃॻ೰എ̈́ບ‫̹̯̦ͦ̈́ث‬5ȃΡͼΜ͉́ࢹ௮‫̹̯ͦا‬হၷίυΈρθ
Ȫstrukturierte Behandlungsprogrammeȫ͈͂ྴઠ́ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦ 2002 ාͤ͢৘ঔ̯̹ͦ6ȃ΂ȜΑΠρςͺ͉́Ȃ2005 ා̥ͣΟͻΐȜΒζΥΐιϋ
ΠȆίυΈρθ൵ව͈৘બࡄ‫̦ݪ‬ଽຸ̧࣐̤̽̀̈́ͩͦ̀̀ͤ͢ͅ7Ȃ̹͘ΟͻΐȜΒȆζΥΐιϋΠॲު͈মު৪౬ఘ଼̯̞ࠫͦ̀ͥ͜8ȃΏϋ΄εȜσ͉́ȂΏϋ΄εȜσ͈ΰσΑΉͺ΍ȜΫΑ͈‫ݯރ‬ఘଷ̵ࣣͩ̀ͅȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̜́ͥ
Chronic Disease Management Programme ̦৘ঔ̯̞ͦ̀ͥ9ȃ̭͈̠͢ͅȂ‫࠷ࢊם‬Ȃ؎ਗ̤͍͢ͺΐͺ͈Ώϋ΄εȜσ́൵ව̯̞̹͈̜ͦ̀̽́ͥȃ╙  ▵ ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻ߩ↪ᴺߩᄙ⟵ᕈߣᧄႎ๔ᦠߩቯ⟵࡮↪ᴺ
! ! ΟͻΐȜΒȆζΥΐιϋΠ͉Ȃ֑̠໲ྤ́։̈́ͥփྙͅဥ̞̤ͣͦ̀ͤȂඅͅ๱‫ࢊם‬
Pilnick, A et al,” Disease management: definitions, difficulties and future directions”,
Bulletin of the World Health Organization, 79: 755–763, 2001.
4 Dixon J et al, "Managing Chronic Disease: WHAT CAN WE LEARN FROM THE US
EXPERIENCE?", King's Fund, 2004.
5 Matrix Research and Consultancy,” Managing chronic disease – what to do as a healthand social care community - learning from Kaiser, Pfizer and United Healthcare in
England" , 2004(visited March 14,2012)<http://www.natpact.info/cms/345.php%e3%80%80>.
6ઐུੳྶȶΡͼΜ̤̫ͥͅ৖ພ‫ۯ‬ၑίυΈρθȷȪ༗࠲֓ၷ‫ڠش‬ల  ‫ے‬ల  ࣢  ාȫ
7 Sharing Health Care Initiative(SHCI)(visited November 6,2008)<http://www.health.gov.au/internet/main/publishing.nsf/Content/chronicdisease-s
haring.htm>.
8 http://www.adma.org.au/index.html (visited November 6, 2008).
9 Health Promotion Board (HPB)-Chronic Diseases(accessed March 14,2012)<http://www.hpb.gov.sg/chronicdiseases/default.aspx?id=4570>.
3-8-࠷̷͈́߹̦࢜‫͈̞́ޑ‬૧̹ͅ೰̱݅ೄ̧̳͓̜͈́ͥ͂ঐഊ̦̜ͥ10ȃΟͻΐȜΒȆζΥΐιϋΠ͈ဥ༹͉Ȃ̭͈࡞ဩ̦୆̹ͦ͘ༀ࣭̤̞̀͜ͅఉ݅എͅঀဥ̯̞ͦ̀ͥȃ̷͈̥̈́́͜Ȃඅ೰͈ਬ౬̜́ͥ Population ஠ఘͬచય̳̥͂ͥȂඅ೰͈ਬ౬͈̠̻Ȃhigh
risk ৪͈͙ͬచય̳̥͂ͥͅఱ༆̧́ͥȃஜ৪͈ങ߿͉ȂDMAA ̦೹੹̱̹Ȃষ͈೰̜݅́ͥȃ̷͈೰͉݅Ȃȶۛ৪ͥ͢ͅুࡨ‫ۯ‬ၑ഼͈ႁ̦࢘‫̜̦ͥ࠯ૄ̬̜ͥͬض‬చયਬ౬ͅచ̱̀ȂΰσΑΉͺ̤̞̀ͅ‫̳ͥ߸۾‬൚ম৪ͬ‫̵̯಺ފ‬ၻࢡ̈́ࠫ‫̠ͥ̈́͂͢ض‬Ȃ൱̧̥̫͂΋ηνΣΉȜΏοϋͬ৘ঔ̳ͥΏΑΞθȷ̜́ͥȃDMAA ͈೰͉݅́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦చય̳͂ͥ
ਬ౬͉Ȃۛ৪ͥ͢ͅুࡨ‫ۯ‬ၑ഼͈ႁ̦࢘‫̜̦ͥ࠯ૄ̬̜ͥͬض‬৖ۛͬခ̳ͥਬ౬͂̈́̽
̞̀ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦చય̳͂ͥ৖͉ۛȂ̞̩̜̦̾ͥ͜Ȃ৽̱͂̀ྕ଻৖̜ۛ́ͤȂൠෂພ͈̈́̓඾ུ̞̠́୆‫ڰ‬ਠ‫۝‬ພ̜́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈చય৪͉Ȃ৽ͅྕ଻৖͈ۛۛ৪̤͍͢ထ๵߲̜́ͥȃ̭ͦͣྕ଻৖͈ۛۛ৪̤͍͢ထ๵߲͈৪͉Ȃ୆‫ڰ‬ਠ‫͈۝‬٨஝̈́̓ুࡨ‫ۯ‬ၑ͈٨஝̦̜ͦ͊Ȃ৖̦ۛอછȆਹછ‫̳ͥا‬ςΑ·ͬ‫͈̜̦́ͥض̬࢘ͥئ‬Ȃ୆‫ڰ‬ਠ‫͈۝‬٨஝̦࢘‫ૄ̬̜ͥͬض‬࠯̦̜ͥȃ
ࢃ৪͈ങ߿͉ȂKaiser ̦೹੹̱ࢩ̩਋̫ව̞ͦͣͦ̀ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈۷ැ̜́ͥȃഥൡഎ̈́‫ٴ‬௄‫ ༹̜ͥ́ا‬Kaiser Triangle ̹͉͘ Kaiser Pyramid͉ȂςΑ·͈೾ഽͬ‫ͅܖ‬Ȃྕ଻৖͈ۛۛ৪ͬ 3 ͈̾ΈσȜίͅ໦̫ͥ(଎ນ 1-1 ४ચȫȃ̭͈ાࣣȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ȂKaiser Triangle ̹͉͘ Kaiser Pyramid̜ͥͅȂhigh risk ͈‫ٴ‬௄ͅ௺̳ͥ৪ͅచ̳͈̜ͥ́ͥ͜ȃུ༭࣬੥͉́Ȃई၄ͬ๰̫̹ͥ͛ȂȶΟͻΐȜΒȆζΥΐιϋΠȷͬ DMAA ̦೰̳݅ͥਬ౬ͬచય̳͂ͥાࣣͅဥ̞ȂKaiser Triangle ̹͉͘ Kaiser Pyramid ̤̫ͥͅల 2͈ ‫ ٴ‬௄ ͅ చ ̳ ͥ ঑ ‫ ׳‬ٚ ව ί υ Έ ρ θ ͬ Ȃ Ο ͻ ΐ Ȝ Β Ȇ ζ Υ ΐ ι ϋ Π ́ ̈́ ̩ caremanagement ͂ઠ̳̭̳ͥ͂ͥͅȃ̭͉ͦȂCapgemini ͈τεȜΠ11͂൳̲ဥ༹̜́ͥȃ

Schrijvers G, “Disease management: a proposal for a new definition”, International
Journal of Integrated Care, Vol.9, January – March 2009.
11 Capgemini, “The Truth About Disease Management”, 2007.
10-9-࿑⴫ 1-1 Kaiser Triangle ߹ߚߪ Kaiser Pyramid

3

Level 3High complexity
Case management

Level 2High risk
Disease/Care management

2

Level 170-80% of chronic disease patients
Self care support/management1ུ༭࣬੥͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈೰͉݅ȂDMAA ̦೹੹̱̹ΟͻΐȜΒȆζΥΐιϋΠ͈೰݅12ͅେࣺ̞ͤͦ̀ͥ͘΋ϋΓίΠ13ͬ‫׳‬ဥ̱̀Ȃষ͈ါ࠯ͬਰ
௷̳ͥȂΟͻΐȜΒȆζΥΐιϋΠͬ৘ঔ̳ͥίυΈρθ̳͂ͥȃ! ! ӱਬ౬ȪPopulationȫͬచય̳͂ͥȃߓఘഎ͉ͅȂ౷֖Ȇ૖֖Ȇ༗ࡏ‫ح‬ව৪͈̈́̓අ
೰ਬ౬̜́ͥȃහփͅြ̳֭ͥࡢ૽ۛ৪͉చય‫ͥ̈́͂ٸ‬ȃ! ! ӲζΥΐιϋΠȆ΍ͼ·σȪmanagement cycleȫͬခ̳ͥȃ ৖ພͬඅ೰̱Ȃߓఘഎ̈́࿒ດͬ୭೰̱Ȃࠫ‫͈ض‬ບ‫ث‬٨஝࣐̠ͬζΥΐιϋΠ΍ͼ·σ͈ι΃ΣΒθ̦̜ͥȃ! ! ӳΉͺȆ΋ȜΟͻΥȜΏοϋ(care coordinationȫฺ̠ͬȃအș̈́૖ਅ̦‫ފ‬൱̱Ȃచય৪Ȇచયਬ౬ͅຈါ̈́Ήͺͬ೹‫̳ͥރ‬ȃ! ! Ӵْࠗၛմ৪̹͉͘๯ဥ໅౜৪͉ȂଽຸȂ֓ၷ༗ࡏ৪Ȃࡹဥ৽̜̈́̓́ͤȂ঑‫׳‬ٚව৪ȆίυΈρθ৘ঔ৪͉ȂႲࠈ̱Ȃૂ༭೒૞ܿ੅ͬ‫ڰ‬ဥ̱̀Ȃ଼‫ͬض‬ਓ͛ͥଛ࣐ෝ
ႁͬခ̳ͥ֓ၷ΍ȜΫΑίυΨͼΘȜ̜́ͥȃ! ̤̈́Ȃ‫࣭ם‬൝͉́ȂChronic Disease Management ͈͂ဥࢊ̦ဥ̞̞ͣͦ̀ͥȃ̭͈ဥࢊ͈̥̈́ͅ Disease Management ̦ව̞͈̽̀ͥ́ई၄ͬઉ̧̳̞͞ȃChronic Disease
Management ͉Ȃ‫଻ྕ͇ٽ‬৖ۛͅ‫̳ͥ۾‬చॐ̜̞͉ͥଽॐ๊֚ͬঐ̳փྙ́ဥ̞ͣͦ̀
̞ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ̷͈చॐ̜̞͉ͥଽॐͬ৘࡛̳ͥ਀౲
̞̠͂պ౾̫̿̈́ͥͅȃDMAA-Disease Management Defined(visited January
6,2007)<http://www.dmaa.org/dm_definition.asp>.
13 ȶ؎ਗ੨࣭͈ΰσΑΉͺΫΐΥΑ̤͍͢ΟͻΐȜΒȆζΥΐιϋΠȷࡄ‫ݪ‬ٛȶༀ࣭̤̫ͥͅ
ΟͻΐȜΒȆζΥΐιϋΠ͈อജȷȪఅ༗ΐλΩϋܱැ़౬஽੥ No.65Ȃ2003 ාȫpp.4-5.
12

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╙  ▵ ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩലᨐߣ⽶ᜂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫͉ض‬Ȃ‫͈̥ͣة‬໅౜̦̜̽̀Ȃই͛̀৘࡛̳
ͥȃ̭̭͉́Ȃࡢ૽Ȃਬ౬Ȃଽॐ͈ 3 ͈̾τασ͈၌ං͂໅౜ͬࣉ̢ͥȃ! ! ࡢ૽͈୆‫ڰ‬ਠ‫͈۝‬٨஝̦Ȃྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພ͈ထཡȂ̳̻̈́ͩȂ৖ພ̦อછȆਹછ‫̳ͥا‬ςΑ·Ȫո‫ئ‬ȶ৖ພςΑ·ȷ̳͂ͥȫ͈೩ࡘ̹̳̭ͬͣ͂ͬ͜৘࡛̳ͥ‫خ‬ෝ଻̦̞̭̦ࣞ͂ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫ࡔ͈ض‬ത̜́ͥȃ૙୆‫ڰ‬Ȃ‫׋‬൲൝͈୆‫ڰ‬ਠ‫͈۝‬٨஝̷͈͂ࠑ௽͉Ȃࡢ૽͈ুࡨ‫ۯ‬ၑෝႁͅջం̳ͥȃਲ̽̀ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̤̫ͥͅȂࡢ૽̫࢜ίυΈρθ͉Ȃࡢ૽͈ুࡨ‫ۯ‬ၑෝႁ͈࢜ષȆ٨஝ͬ঑‫̳ͥ׳‬ٚවฺ̠ͬȃఉ̩͈ࡢ૽̫࢜ίυΈρθ͉ȂίυΈρθ͈చય͂̈́ͥࡢ૽͈ুࡨ࢘ႁۜͬ‫اޑ‬௯ૺ̱ুࡨ‫ۯ‬ၑෝႁͬ࢜ષ̵̯̭ͥ͂ͅಕႁ̱̞̀ͥȃࡢ૽τασ͈໅౜̱͉͂̀Ȃ୆‫ڰ‬ਠ‫ͬ۝‬٨஝̳࣐ͥ൲་ယ৾ͤͅழ͚Ȃশ‫ۼ‬എୈ૰എࠐ
फഎ໅౜̦୆̲ͥȃ! ਬ౬τασ͉́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ༗࠲୺࿝૖̦ࡢ૽ͅచ̱
̀ুࡨ‫ۯ‬ၑෝႁͬ࢜ષ٨஝̳ͥ঑‫׳‬ٚව࣐̠ͬ‫ڰ‬൲ͬ৘࣐̳ͥȃ̱̥̱Ȃࡢ૽ࡢ૽͈ે
ఠȆે‫͉ޙ‬։̈́ͥȃ̳͓͈̀ࡢ૽ͅ൳̲ࡢ૽̫࢜ίυΈρθͬഐဥ̱̀͜൳̲࢘‫͉ض‬୆̲̞̈́ȃ̹͘Ȃ͈̓ࡢ૽̫࢜ίυΈρθ́͜Ȃ̳͓͈̀ࡢ૽ͅచ̷̱͈̀͜୆‫ڰ‬ਠ‫ͬ۝‬٨஝̵̯̭͉ͥ͂Ȃະ‫خ‬ෝ̜́ͥȃਬ౬̫࢜ίυΈρθ̜͉̽̀ͅȂࡢ૽͈͒঑‫׳‬ٚවͅঀ̢ͥ঩࡙͉ࡠ̞̭ͣͦ̀ͥ͂ͬࣉၪ̱̹৾ழ̦̯̈́ͦͥȃ႕̢͊Ȃ‫ٴ‬௄‫͉̓̈́ا‬Ȃ̷͈঩࡙࢘ၚ଻ͬࣞ͛ͥ਀༹͈̜͌͂̾́ͥȃਬ౬τασ͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫͂ض‬໅౜͉Ȃඅ೰͈ਬ౬ͅచ̱̀Ȃ୺࿝૖͈Ⴛႁ̈́̓ͬൎව̱Ḁ͈̑̈́ͭͣ࠲ࢫঐດ͈٨஝Ȫͺ;Π΃θ͂ࡤ̭̦͊ͦͥ͂ఉ̞ȫͬ৘࡛̳ͥ͂௴̢̭̦ͥ͂́
̧ͥȃͺ;Π΃θ̱͂̀नဥ̯ͦͥঐດ͉ȂࠬգȂఘਹ൝͈୆ఘତ౵଼̤͍ࣣ͢ঐତ̦
̜ͥȃίυΈρθ৘ঔࢃ͈ͺ;Π΃θ͈٨஝͉Ȃਬ౬͈৖ພςΑ·͈೩ࡘ̱͂̀෤՜̳
̧̭ͥ͂́ͥ͜ȃςΑ·ͬ೩ࡘ̧̹́ࡢ૽ͬ௩‫̵̭̹̯͂͜ح‬Ȃ଼‫خ̭̳͂ͥ͂͜ض‬ෝ̜́ͥȃଽॐτασ͈́࢘‫͂ض‬໅౜ͅ‫̱̀۾‬Ȃ৽ါ̈́໅౜़͉ଽ໅౜̜́ͥȃ͈̠̓̈́࢘͢‫ض‬ͬ࿒ঐ̳̥͉Ȃાࣣ̽̀͢ͅ։̈́ͥȃఉ̩͈࣭ș͉́Ȃྕ଻৖ۛచॐͬ৘ঔ̳̥ͥ̈́́
̷͈࢘‫ͬض‬೰̞͛̀ͥȃྕ଻৖ۛచॐ͉ȂίρͼζςΉͺ٨‫͈֚ڟ‬໐̱̜̞͉͂̀ͥ૬
̞‫۾‬Ⴒ଻ͬ঵̽̀৘ঔ̯̞ͦ̀ͥȃྕ଻৖ۛచॐ̱͂̀৘ঔ̯ͦͥΟͻΐȜΒζΥΐι
ϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͉ȂౙͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫̺ض‬̫̩́̈́Ȃͤ͢ࢩํս̜̞͉ͥࣞষ͈ଽॐ͈̥̠̈́̓ͅպ౾̫̞̥̿ͣͦ̀ͥͅ‫ͥͩ۾‬࿂̦̜ͥȃ႕̢͊Ȃ࣭ྦྷ֓ၷ๯͈௩ఱ߹࢜ͬဲଷ̳ͥଽॐ͈̥̈́ͅȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ̦պ౾̫̭̦̜̿ͣͦͥ͂ͥȃ̹͘Ȃ‫ܢ଻ݢ‬৖̥ۛͣྕ଻৖͈ۛ͒ΏέΠͅచ؊̳ͥȂ૧̱̞‫ݯރ‬ΏΑΞθ͈͒֊࣐ͬ௯ૺ̳ͥଽॐ͈͌͂̾
̠̈́ͤͥ͜ͅȃ-11-╙  ▵ ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ․ᕈߣᄙ᭽ᕈ
! ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃྕ଻৖ۛͅ‫̳ͥ۾‬ထཡ঑‫׳‬ίυΈρθ̜́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃࡢ૽͈࠲ࢫςΑ·͈٨஝̦ਬୟ̱̀ίυΈρθ͈࢘‫̦ض‬อ‫̳ͥܞ‬ȃྕ଻৖͉ۛহ࿴̱̞̦̈́Ȃ‫׋‬൲૙ম‫͈̓̈́׸ݎ‬୆‫ڰ‬ਠ‫ͬ۝‬٨஝̷̳̭͈ͥ͂ͤ͢ͅςΑ·έ͹·ΗȜ͉٨஝̧̳̭̦ͥ͂́ͥȃࡢ૽͈୆‫ڰ‬ਠ‫͈۝‬٨஝ͬ঑‫ࠑ̱׳‬௽̳̹ͥ͛ͅȂࡢ૽͈ζΥΐιϋΠ΍ͼ·σ‫ۯ‬ၑȆ঑‫୺̠࣐ͬ׳‬࿝૖Ȫఉ૖ਅȫ̦‫ފ‬൱̱̀৘ঔ̳ͥຈါ̦̜ͥȃ!
! ! చય̱̞͈͉͂̀ͥȂࡢ૽̺̫̩́̈́Ȃਬ౬͜చય̱̞̀ͥͅȃ৾ͤષ̬ͥထཡ͈ํ
ս̤͍͢చય̳͂ͥਬ౬͈ܰ࿅̽̀͢ͅఉအ̈́ࠁఠ̦୆̭ͦͥ͂̈́ͥ͘ͅȃ႕̢͊Ȃൡࣣഎ̈́ΰσΑΉͺ΍ȜΫΑͬ೹‫ܰ઀̞̱ͥ̀ރ‬࿅͈ਬ౬ͅచ̱֚̀ষထཡ̥ͣ२ষထཡ
́ͬ͘೹‫ࠁ̳ͥރ‬ఠȂಎܰ࿅͈ۛ৪ਬ౬ͅచ̱̀ඵষထཡ͂२ষထཡͬ೹‫ࠁ̳ͥރ‬ఠȂಎܰ࿅̥ͣఱܰ࿅͈ਬ౬ͅచ̱֚̀ষထཡͬ೹‫ࠁ̳ͥރ‬ఠ̜̈́̓́ͥȃȪ଎ນ 1-2 ४ચȫ࿑⴫ 1-2 ੍㒐ߩ▸࿐߅ࠃ߮ኻ⽎㓸࿅
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! ! ̹͘ȂΰσΑΉͺ೹‫ރ‬ΏΑΞθ͈٨‫ͦͣ͛ૺ̦ڟ‬ଷഽ٨ୃ̦̯̈́ͦͥ͂Ȃ̷ͦͅ؊̲
̹ࠁఠ́ထཡ͈ํս͞చયਬ౬ͅ་‫̦ا‬୆̲̭̜ͥ͂ͥ͜ȃ╙  ▵ ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓ᡽╷ߩᒰ੐⠪ߣ᭴ᚑⷐ⚛ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐͅ‫̳ͥ۾‬൚ম৪ͬࣉ̢ͥ͂ষ͈͂

-12-̤ͤ͂̈́ͥȃ̳̻̈́ͩȂࡢ૽͉Ȃࡢ૽̫࢜ίυΈρθͅ‫̳ͥ۾‬΍ȜΫΑ೹‫ͬރ‬਋̫Ȃু໦͈ίυΈρθͬ৘࣐̳ͥȃ̭̭͉́Ȃ൚ম৪͉ȂΰσΑΉͺ୺࿝૖̜́ͥ঑‫׳‬ٚව৪͂ু໦͈ίυΈρθͬ৘࣐̳ͥࡢ૽̜́ͥȃ̷͈ࡢ૽͉Ȃྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພ͈ۛ৪̷̤͍͈͢‫خ‬ෝ଻̦̜ͥ৪̜́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ͅȂࡢ૽̫࢜ίυΈρθ̺̫̩́̈́Ȃ̜ͥඅ೰͈ਬ౬(population)ͅచ̳ͥίυΈρθ̜ͥ͜ȃਬ౬̫࢜ίυΈρθ͉Ȃඅ೰͈ਬ౬ͅ‫̱̀۾‬Ȃ‫ٴ‬௄‫̞࣐ͬا‬Ȃ̷͈‫ٴ‬௄̷̮͈͂ͅ‫ٴ‬௄ͅ௺̳ͥࡢ૽ͅచ̱̀ഐࣣഎ̈́঑‫׳‬ٚවͬ৘ঔ̳ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ
ͬ৘ঔ̳ͥଽॐْ̱ͬࠗၛմ̱Ȃ̷̯͈ͣͅ๯ဥͬ໅౜̳ͥ৪̦̜̽̀Ȃই͛̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦৘࣐̯ͦͥȃ̷͈৪͉Ȃْࠗၛմ৪̜́ͤȂ๯ဥ໅౜৪̜́ͥȃఉ̩͈ાࣣȂၰ৪͉֚౿̳ͥȃΩͼυΛΠഎমުͬ৘ঔ̳ͥાࣣ͉Ȃْࠗၛմ৪͂๯ဥ໅౜৪͉༆ș́͜৘̧࣐́ͥȃ̱̥̱ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦Ȃழ૕എ̥̾ࠑ௽എͅ୽ၞഎ̈́ࡉ౷̥ͣ৘ঔ̯ͦͥાࣣ͉ͅȂၰ৪̦֚౿̳̭ͥ͂
๊̦֚എ̜́ͥȃ̶̈́̈́ͣȂ̜ͥ࢘‫̭̬̜ͬ͂ͥͬض‬࿒എͅমުْ͉̯ࠗͦ৘࣐̯ͦȂ̷̱̀ࠫ‫͉ض‬ບ‫̯ͦث‬Ȃ٨ၻ̦௽̫̭̦ͣͦͥ͂Ȃ୽ၞഎ࢘‫ض‬എ̈́ΟͻΐȜΒζΥΐι
ϋΠȆίυΈρθ͈৘࣐͉ͅຈါ̺̥̜ͣ́ͥȃ๯ဥ໅౜͉ͅȂ࿒എ͂࢘‫ض‬෤՜ͬຈ̴
ฺ̠ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬࠑ௽എ୽ၞഎͅଛ࣐̳ͥ৽ఘ͉Ȃଽຸ‫ܥ‬‫۾‬Ȫ़ଽந౾̧̦́ͥȫȂ֓ၷ༗ࡏ৪Ȫ༗࠲মު̱͂̀๯ဥ঑੄̧̦́ͥȫ̹͉͘ࡹဥ৽
(ॲު༗࠲͈۪̱֚͂̀๯ဥ঑੄ͬࠨ೰̧́ͥȫ̜́ͥȃ̭͈‫ͬ߸۾‬଎া̱̹͈̦Ȃ଎ນ
1-3 ̜́ͥȃ-13-

࿑⴫ 1-3 ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓ᡽╷ߩᒰ੐⠪ۛ৪Ȇۛ৪ထ๵߲
చય͈අ೰‫ا‬
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๯
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๯ဥ໅౜

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ව
৪
⟣
⤅
⤘
⣟
⤔
⤎
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ਬ౬̫࢜
ίυΈρθ

ࡢ૽̫࢜
ίυΈρ

ଽຸ

֓঍Ȇۭࢌ঍, ै

අ೰͈ਬ౬

֓ၷ༗ࡏ৪

ުၷ༹আȂၑ‫ڠ‬(population)ࡹဥ৽ၷ༹আȂ‫ူו‬আ̷͈ఈ୺࿝૖

ΟͻΐȜΒζΥΐιϋΠȆίυΈρθଽॐͬ৘ঔ̳͉ͥͅȂઁ̩̈́͂͜ո‫଼ࢹ͈ئ‬ါளͬ‫͚܄‬ຈါ̦̜ͥȃల֚ͅȂͼϋέρΑΠρ·ΙλȜ̜́ͥȃ֓঍Ȇۭࢌ঍Ȃैުၷ༹আ൝͈֓ၷȆ༗࠲ͅਲম̳ͥ୺࿝૖̦చયͅచ̱̀‫ފ‬൱̱̀঑‫׳‬ٚව࣐̠͉ͬͅȂૂ༭‫ވ‬ခΏΑΞθ̦ຈါ̜́ͤȂζΥΐιϋΠ΍ͼ·σ͈ι΃ΣΒθͬ৘ঔ̳͉ͥͅ‫߸۾‬൚ম৪̦‫ވ‬೒ͅঀဥ̧́ͥ
ൡ֚എૂ༭έ΁ȜζΛΠ̦ຈါ̜́ͥȃలඵͅςΕȜΆ̜ͥȃςΕȜΑ͉Ȃ๯ဥ໅౜̳
़ً࡙̺̫̩ͥ́̈́‫ͥͦ͘܄̓̈́͜ࡑࠐ͈ݲ‬ȃల२ͅίυΈρθ͈ίυΠ΋σ̜́ͥȃఉତ൚ম৪̦‫ͅڲ׫‬ίυΈρθͬ‫̧͉̹͛ͥ́ͅא׋‬Ȃྶ‫̈́ږ‬ίυΠ΋σ͈໲ડ‫̦ا‬ະ‫ࠧخ‬̜́ͥȃలঅͅ‫߸۾‬൚ম৪͈ͼϋΓϋΞͻή͈໦ଢ଼͂୭̦̜ࠗͥȃచય৪ࡢ૽͉ͅ୆‫ڰ‬ਠ‫۝‬٨஝͈൲‫̫ັܥ‬Ȃ֓ၷȆ༗࠲ͅਲম̳ͥ୺࿝૖͉ͅ߄஘എୈ૰എ༭ੲΏΑΞθ̦ຈါ̜́ͥȃలࡼͅଽॐບ‫͈ث‬ΏΑΞθ͜ະ‫̜ͥ́ࠧخ‬ȃ! ଽॐജ‫͈ٳ‬ႀ֖͉Ȃࡢș͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬࡢ૽̹͉͘ਬ౬ͅഐဥ̳ͥτασ̳̭́ۖࠫͥ͂́फ͚ાࣣȂΰσΑΉͺΏΑΞθ͈೹‫ރ‬ఘଷͬ་ࢵ̳ͥຈါ̦̜ͥτασ́͘ജ‫̳ͥٳ‬ાࣣȂٚࢌ΍ȜΫΑ̜̞͉ͥ social care14́͘‫̹͛܄‬ಿ‫͈ۼܢ‬Ω
14඾ુ୆‫ڰ‬൲ैࣾͅඳͬခ̳ͥ৪ͅచ̱̀Ȃ૸ఘٚ੩Ȃවဵ͈̈́̓໙ࢩ̞΍ȜΫΑͬ೹‫̳ͥރ‬̭͂ȪDepartment of Health, “What’s What: a glossary of terms used in DH”ȫȃ

-14-ȜΑβ·Ξͻήͬ‫͚܄‬ાࣣ̦̜ͥȃ̷̸͈ͦͦાࣣ́ͺίυȜΙ̦։̈́ͥ15ȃ╙  ▵ ࡋ࡞ࠬࠤࠕࠪࠬ࠹ࡓߩ․ᓽߣ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓታ
ᣉᣇᴺΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͉ȂႤঃഎ২ٛഎ໲ྤ͈̥̈́́ജ
‫̯ͥͦٳ‬ȃ৘ঔ̱̞̀ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ൳̲ι΃ΣΒθͬခ̱Ȃ႒য̱̞̀ͥȃ̱̥̱ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬଽॐ̱͂̀৘ঔ̳
༹༷͉ͥఉအ̜́ͥȃ႕̢͊Ȃༀ࣭̤̫ͥͅྦྷ‫৽ۼ‬ఘ͈ΰσΑΉͺΏΑΞθ͉́Ȃྦྷ‫ۼ‬༗ࡏ৪̥ͣ࢖എଷഽ͒ജ‫̹̱ٳ‬ȃΡͼΜ͉́Ȃྦྷ‫ۼ‬༗ࡏ৪̩́̈́࢖എ֓ၷ༗ࡏ৪̦नဥ
̱̹ȃ̷͈ఉအ଻͉Ȃଽॐࠁ଼͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔ̦Ȃ̷̸͈࣭͈ͦͦΰσΑΉͺΏΑΞθ̦֑̠අಭ͂Ⴄঃഎജ‫ͬٳ‬঵̞̽̀ͥ΋ϋΞ΅ΑΠ͈̥̜̹̜̈́ͥ͛́ͥͅȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔ༹༷͂ଽॐͬၑٜ̳ͥͅ
͉ȂΰσΑΉͺΏΑΞθ͈අಭȆ‫ͬڟ״‬ၑٜ̱ȂίυΈρθ৘ঔ༹༷ͬ২ٛഎ΋ϋΞ΅ΑΠ͈̥̈́́ၑٜ̳ͥຈါ̦̜ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬȂίρͼζςΉͺͅպ౾̫̿̀৘ঔ̱̞̀ͥ
࣭̦̜ͥȃༀ࣭Ȃ΃΢ΘȂ؎ਗȂ΂ȜΑΠρςͺ͉̈́̓́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔ༹༷ͬ࠿൦̱Ȃ݈ა̳ͥषͅȂWagner ̦೹੹̱̹ Chronic Care Model16͈‫ٽ‬ැ଎̦Ȃ୰ྶͅဥ̞̭̦ͣͦͥ͂ఉ̞(଎ນ 1-4 ४ચȫȃChronic Care Model ͉Ȃ΋ηνΣΞͻ̤̫ͥͅȂٚࢌȪlong term careȫ́͘‫̹͛܄‬ȂίρͼζςΉͺ̤̫ͥͅྕ଻
৖ۛͅ‫̳ͥ۾‬ΉͺκΟσ̱ܱ͂̀੆̯̞ͦ̀ͥȃ

Debbie Singh,” How can chronic disease management programmes operate acrosscare settings and providers?” WHO Regional Office for Europe, 2008.
16 Wagner.”Chronic Disease Management: What will it take to improve care for chronic
illness” Effective Clinical Practice, Volume 1 Number 1, August/September 1998.
15

-15-

࿑⴫ 1-4 Chronic Care Model

Community
Resources
and policies

Health System
Organization of Health Care

Selfmanagement
supportInformed
activatedpatient

DeliverysystemdesignProductivePinteractions
nter
eraction

Decision
supportClinicalinformation
systems

Preparedproactive
practice team

Functional and Clinical Outcomes
Chronic Care Model ͉ͅȂষ͈ 6 ͈̾ါள̦̜ͥȃ̳̻̈́ͩȂΰσΑȆΏΑΞθ̤̫ͥͅȂΰσΑΉͺ΍ȜΫΑ͈ழ૕(health care organisation (HCO)ȫ, ΰσΑΉͺ΍ȜΫΑ͈‫ݯރ‬ΏΑΞθ͈୭ࠗ(delivery system design (DSD)ȫ, փএࠨ೰͈͒঑
‫(׳‬decision support (DS)ȫ, ႉ઄ͅ‫ૂ̳ͥ۾‬༭ΏΑΞθ(clinical information system(CIS)ȫ, ুࡨ‫ۯ‬ၑͅచ̳ͥ঑‫(׳‬self management support (SMS)ȫȂ̤͍͢΋ηνΣΞͻ̤̫ͥͅ community resources (CR)̜́ͥȃ̯ͣͅȂૂ༭ͬ਱໦ං̹ۛ৪͂਱
໦ͅ੔๵̯̹ͦΰσΑΉͺ΍ȜΫΑ͈ၰ༷̦̜ͥȃ! ! ! ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔ༹༷͂ଽॐͬၑٜ̳͉ͥͅȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ίρͼζςΉͺ̜̞͉ͥ community care17͈ႀ֖͈
̥̈́́৘ঔ̯̭ͦͥ͂Ȃ̤͍͢ଽॐ͈ࠁ଼͂ജ‫͉ٳ‬ίρͼζςΉͺ̜̞͉ͥ΋ηνΣΞͻΉͺ͈ႀ֖͈̱̯̭͌͂̾͂̀̈́ͦͥ͂ͅၣփ̳ͥຈါ̦̜ͥȃ╙  ▵ ᡽ᴦ⚻ᷣ⊛ߥ᡽╷ᒻᚑዷ㐿֓ၷ༗ࡏ৪̦Ȃুࡨ͈মުജ‫ͅٳ‬ष̱̀ȂΫΐΥΑεςΏȜ̱͂̀ΟͻΐȜΒζΥΐι
ϋΠȆίυΈρθͬ൵ව̳ͥष͉ͅȂ୺ͣࠐफഎါ֦́փএࠨ೰̳ͥȃ̱̥̱Ȃଽຸ̦࢖17ۛ৪Ȇવ‫ٺ‬৪ȆࣞႢ৪ͅచ̱̀ȂΣȜΡͅ‫̧̿ܖ‬डఱࡠুၛ̱̀౷֖́୆‫̧̠ͥ́͢ͅڰ‬΍ȜΫΑ೹‫͂ރ‬঑‫̠࣐ͬ׳‬Ήͺ̞̠ͬ(White T, “A Guide to NHS”, 2010, pp38-39.ȫȃ

-16-എ̈́ଽॐ̱͂̀ΟͻΐȜΒȆζΥΐιϋΠͅ‫̳ͥ۾‬ଽॐͬ৘ঔ̱̠̳͂ͥ͂͢Ȃଽহࠐफഎ̈́໲ྤ͈̥͈̈́́ଽॐജ‫ͥ̈́ͅٳ‬ȃ႕̢͊Ȃ‫̞̀̾ͅޙે͈࣭ם‬Ȃষ͈̠͢ͅຝৢ̯ͦ
̞̀ͥȃ༗࠲֓ၷଽॐͬၛմ̳͈͉ͥଽࡀൂ̜́ͥȃNational Health ServiceȪNHSȫ͈঩߄಺ో͂‫ͅא׋‬ୣහͬ໅̠༗࠲જ͉‫ڝ‬ၯ̦ၚ̞̞̀ͥȃΰσΑΉͺ͈٨஝͉Ȃ࡛ह͈ଽহ‫ه‬ఴ͈࿹୶ম̜ࣜ́ͤȂड߃͉֓ၷ΍ȜΫΑ͈͒ͺ·ΓΑ࢜ષͅఉ‫͈ڣ‬ထॳ̦ழͦ̀͘
̞ͥȃ‫࣭͜ם‬ఈ͈࣭‫͂ز‬൳̲ે‫́ޙ‬ȂࣞႢ‫଻ྕ͂ا‬৖ۛͥ͢ͅ໅‫͈ك‬௩ఱͤ֓͢ͅၷଷഽ
़͉ଽඳͅ‫̞ͥ̀̽ۿ‬ȃଽຸ͉̭ͦͅచ؊̳̹ͥ͛Ȃ৖ۛထཡȂ࠲ࢫ௯ૺȂΓσέΉͺ͂౷֖֓ၷͬ௯ૺ̳ͥଷഽͅ࿹୶̱̀ထॳͬ෻໦̱̞̀ͥȃ̷͈࿒എ͉Ȃ֚ষ֓ၷ͉́֓ၷ
΍ȜΫΑ೹‫͈ރ‬๯ဥ࢘‫̠̞̞̦͂ࣞض‬ଔ౯ͅ‫̧̿ܖ‬Ȃ֓ၷ΍ȜΫΑ͈೹‫ͬރ‬ඵষ֓ၷ̥ͣ
৘࣐‫خ‬ෝ଻͈̞֚ࣞষ֓ၷͅ֊̵࣐̯̭̜ͥ͂ͥͅȃ୶ૺ࣭͉́ȂΰσΑΉͺͅ‫۾̳ͥ۾‬૤̩ࣞ͜Ȃଽহഎ̈́௔ത͞ਹါ̈́ଽॐ‫ه‬ఴ̈́ͥͅȃ̯ͣͅȂ၌‫߸۾ٺ‬৪̦υΫȜ‫ڰ‬൲࣐̠̭ͬ͂͜ఉ̩̜ͥȃଽॐࠁ଼̜̹͉̽̀ͅȂౙ֓ͅၷࠐफഎࣣͅၑഎ̥̠̥̠̥̺̫̩̓̓́̈́Ȃଽহഎͅఏ‫̱ފ‬৘̧࡛̥͈́ͥ͂ণത̦ຈ
ါ̈́ͥͅȃ

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╙  ┨ ฦ࿖ߩ࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߦ㑐ߔࠆ᡽╷╙  ▵ ฦ࿖ߩ⸥ㅀߩ᭴ᚑ࡮ಽᨆⷞⷺ
! ষ͈ 3 ̾ͅ‫̳ͥ੆ܱ̱̀۾‬ȃӱΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐͅ‫̳ͥ۾‬෸ࠊ! ! ଽॐࠁ଼͂ജ‫͈ٳ‬෸ࠊͬȂո‫͈ئ‬തͬಎ૤ͅ୰ྶ̳ͥȃȆ࣭͈‫ޙٽ‬ȪඅಭȆ‫ڟ״‬ȫȆΰσΑΉͺΏΑΞθ͈අಭȪ೹‫ރ‬ఘଷ़࡙͂಺ో༹༷ȫ̤͍͢ΰσΑΉͺଽॐȆଽࡀ͈་஗Ȇྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθ৘༹࣐͈̹͈༷͛Ȇ஖఼ঠȪߓఘഎ͉ͅȂْၛմ৪Ȇ๯ဥ໅౜৪Ȃ঑‫׳‬ٚව৪ȆίυΈρθ৘ঔ৪൝͈൚ম৪Ȇ৘ঔ༹༷͈஖఼
ঠȫӲΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐͅ‫ڟ״̳ͥ۾‬! ! ! শࠏႥഎͅ୰ྶ̳ͥȃಈষ٨ୃ̦̯̞̭̦̈́ͦ̀ͥ͂ఉ̞̦Ȃ̷͈ၑဇͬ୰ྶ̳ͥȃ! ! ! ఉ̩͈ાࣣȂྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθ͈ଽॐ͉ȂίρͼζςΉͺ٨‫ڟ‬͈۪̱֚͂̀ၛմ̯ͦଔૺ̯ͦͥȃߓఘഎ͉ͅȂࣞ‫̈́ڣ‬ພ֭঩࡙͈ঀဥॉࡘȂව֭Ȇठව͈֭ࡘઁȂ̤͍͢ව֭‫͈ۼܢ‬ౣੀ̦̈́̓ࣉၪ̯ͦͥതͬ୰ྶ̳ͥȃӳΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࡛ે͂ଽॐ‫ه‬ఴ
! ! ! ଽॐ͈࡛ે͂‫ه‬ఴͬାၑ̱ܱ̀੆̱̞̀ͥȃ̹̺̱Ȃ̷̸͈࣭̤̞ͦͦ̀ͅૂ༭͈
ව਀͈ଷ࿩̥ͣȂड૧͈শത͉։̞̈́̽̀ͥȃ-18-╙  ▵ ☨࿖18
㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊ӱ࣭͈අಭȆ‫ڟ״‬! ༀ࣭Ȫͺις΃ࣣਤ࣭ȫ͉Ȃ50 ਗ̥ͣ̈́ͥႲཆ࣭‫̜ͤ́ز‬Ȃ࿂ୟ 962.8 ྔ໹༷΅υιȜΠσȪ඾ུ͈࿩ 25 ෼ȫ͈ࢩఱ࣭̈́ാͬခ̱̞̀ͥȃ૽࢛ 3 ‫ ؙ‬875 ྔ૽Ȫ2010 ාȫͬသ̳ͥఉྦྷ௼࣭‫̜ͥ́ز‬ȃࠐफܰ࿅͉ଲ‫ٮ‬डఱ̜́ͤȂ2010 ා͈ྴ࿒ GDP ͉ 14 ಣ 6,604 ‫ؙ‬ΡσȂ1 ૽൚̹ͤྴ࿒ GDP ͉ 47,284 Ρσ̜́ͥȃ! ଽহ࿂͉́Ȃ‫ވ‬გൂ͂ྦྷ৽ൂͥ͢ͅ 2 ఱଽൂଷ̦೰಍̱̞̀ͥȃༀ࣭͈֓ၷ༗વ଼͈ͤ
ၛ̻ͅ‫͉̱̀۾‬Ȃ‫ވ‬გൂ͂ྦྷ৽ൂ̦ଽࡀ࢐ఢͬ߫ͤ༐̧̱̞̭̦̀̀ͥ͂ఱ̧̩‫̱̀ޣג‬̞ͥȃঌાࠐफͬਹণ̱֓ၷ໦࿤̤̞̀͜ͅଽຸ͈ٚවͬဲ̢̠̳͂ͥ͢߹̦̜࢜ͥ‫ވ‬გൂ͂Ȃ২ٛഎ࢖ୃ͈৘࡛͈̹͛ͅଽຸ͈֚೰͈ٚව͉ຈါ̳͂ͥྦྷ৽ൂ͈͂‫́ۼ‬Ȃ֓ၷ༗વ͉ಿා̹ͩ̽̀ͅଽॐ͈௔ത̧̹͂̈́̽̀ȃ! Ⴒཆଷ̜̭͉́ͥ͂ȂΰσΑΉͺͅ‫̳ͥ۾‬ଽॐ̦Ⴒཆ͂ 50 ਗ́ജ‫̭̯ͬ͂ͥͦٳ‬փྙ̳ͥȃႲཆଽຸ͈‫ڰ‬൲̺̫̩́̈́ȂਗଽຸȂߴଽຸ͈൲࢜͜ͅಕ࿒̳ͥຈါ̦̜ͥȃӲΰσΑΉͺΏΑΞθȪ೹‫ރ‬ఘଷ़࡙͂಺ో༹༷ȫ͈අಭ͂‫ڟ״‬! ༀ࣭͈ΰσΑΉͺΏΑΞθ͈ఱ̧̈́අಭ͉Ȃࢩ̩࣭ྦྷ๊֚ͬచય̳͂ͥ࢖എ̈́֓ၷ༗વ
ଷഽ̦ంह̵̴Ȃయͩͤͅྦྷ‫ۼ‬༗ࡏٛ২̧̦֨਋̫࣐̠ͬྦྷ‫ࢫ࠲ۼ‬༗ࡏ̦֓ၷ༗વ͈࿂́
ఱ̧̈́࿨‫ͬڬ‬౜̞̭̜̽̀ͥ͂ͧͥͅȃ࢖എ̈́֓ၷ༗વଷഽ͉ȂࣞႢ৪Ȃ೩ਫ਼ං৪̈́̓ςΑ·̦̩ࣞȂ̹͉͘Ȃࠐफഎͅྦྷ‫ࢫ࠲ۼ‬༗ࡏͅ‫ح‬ව̳̭̦ͥ͂ඳ̱̞૽ͬచય̱͂̀ା๵
̯̞ͦ̀ͥȃ̭͈̠̈́֓͢ၷ༗વଷഽ͈̜༷͉ͤ࢖എଷഽ͂ྦྷ‫ۼ‬༗ࡏ͈ईࣣȪmixtureȫ͂ນ࡛̯ͦͥȃ
! ֓ၷ೹‫ރ‬ఘଷ͈࿂͉́Ȃ֓ၷίυΨͼΘȜ͈‫ܥ‬ෝ໦‫̞ͥ́ͭૺ̦ا‬ȃ̹͘Ȃ֓ၷίυΨͼΘȜ͈ΥΛΠχȜ·‫̞ͥ́ͭૺ͜ا‬ȃζΥΐΡΉͺ͈ΏΑΞθ͉́ gate keeper എ̥̥̫̈́ͤ̾֓ଷഽ̦नဥ๊̯̞̭̦֚ͦ̀ͥ͂എ̜́ͥȃ̹̺̱ȂζΥΐΡΉͺΏΑΞθ‫́ٸ‬͉೏‫ح‬എ̈́๯ဥ໅౜ͤ֓͢ͅၷ΍ȜΫΑίυΨͼΘȜ௰ͅুဇͅͺ·ΓΑ̳̭͉ͥ͂‫خ‬ෝ̜́ͥȃ̭̠̱̹֓ၷ೹‫ރ‬ఘଷ͈̥̈́́Ȃඵষ֓ၷ͉͂‫ܥ‬ෝ̦ߊ༆̯̹ͦίρͼζςΉͺȪPrimary Careȫ͈໦࿤̦ంह̱̞͈̀ͥ͂ྶ‫̈́ږ‬۷ැ̦ంह̱̞̀ͥȃ! ࢖എଷഽ̜́ͥȂ೩ਫ਼ං৪̫࢜֓ၷ༗વଷഽιΟͻΉͼΡ͈‫৽א׋‬ఘ͉ਗଽຸ̜́ͤȂࣞႢ৪̫࢜֓ၷ༗વଷഽιΟͻΉͺ͈‫৽א׋‬ఘ͉Ⴒཆଽຸ̜́ͥȃ̹͘ȂιΟͻΉͼΡͅ‫̱̀͜۾‬Ȃ̷͈‫ۼྦྷ̦א׋‬༗ࡏٛ২൝ͅտు̯̞ͦ̀ͥાࣣ͜ఉ̩Ȃ࢖എଷഽ͈ಎ̤̞ͅ
ུ୯͈ܱ੆͉Ȃ̷͈ఉ̩ͬո‫ ̬ͥࠇͅئ‬3 ໲ࡃͅ‫̞ͥ̀̽ݶ‬ȃȶ؎ਗ੨࣭͈ΰσΑΉͺΫΐΥΑ̤͍͢ΟͻΐȜΒȆζΥΐιϋΠȷࡄ‫ݪ‬ٛȶༀ࣭̤̫ͥͅΟͻΐȜΒȆζΥΐιϋΠ͈อജȷȪఅ༗ΐλΩϋܱැ़౬஽੥ No.65Ȃ2003 ාȫȂࢃ൥ՔȆ‫ݛ‬ংຮঃȶༀܑ࣭͈ު̤̫ͥͅ࠲ࢫ௩
ૺȆ৖ພထཡͅ‫̳৾ͥ۾‬ழ͈൲࢜- ΟͻΐȜΒȆζΥΐιϋΠȂ;ͿσΥΑȆίυΈρθͬಎ૤̱͂̀ -ȷ
Ȫఅ༗ΐλΩϋ௙ࡄ·΁ȜΗςȜల 57 ࣢Ȃ2011 ාȫȂ઀ႅඈȶༀ࣭̤̫ͥͅ 2010 ාΰσΑΉͺ٨‫ࢫ࠲͈ࢃڟ‬༗ࡏ͈૧൲࢜! ȡΰσΑΉͺ٨‫ͬة༹͉ڟ‬་̢̹̥Ȃ࠲ࢫ༗ࡏঌા͉̓
̠་‫̥̳ͥا‬ȡȷȪఅ༗ΐλΩϋ௙ࡄτεȜΠల 59 ࣢Ȃ2011 ාȫȃུ୯̤̞̀ͅȂષܱ 3 ໲ࡃͬ४ચ̱̞̀ͥાࣣඅͅ‫ݗ‬ಕͬັ̯̞̈́ȃ

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̀͜Ȃྦྷ‫ۼ‬༗ࡏٛ২̦ఉ̩͈‫ܥ‬ෝͬ౜̞̭̽̀ͥ͂͜ༀ࣭͈අಭ̱̜̬͂̀ͣͦͥȃ࢖എଷഽ͂ྦྷ‫ۼ‬༗ࡏ̦ईࣣ̳ͥ֓ၷ༗વ͈იழ͙͉Ȃ‫ވ‬გൂ͂ྦྷ৽ൂ͈͂‫ੈ͈ۼ‬Ⴇ̈́ଽॐა௔
͈ಎ́Ȃশ͉ͅଽহഎ̈́ఏ‫࣐̦̾̾ͦͩފ‬Ȃ֚೰͈ᣄဒެ୬ͬࠐ̦̈́ͣࠁ଼̧̯̹ͦ̀͜
͈̜́ͥ͂ບ‫̞̯ͥ̀ͦث‬ȃ! ΰσΑΉͺ़͈࡙͉Ȃྦྷ‫ۼ‬ঌા͉́ྦྷ‫ۼ‬༗ࡏ͂ۛ৪͈জ๯໅౜̜́ͥȃྦྷ‫ࢫ࠲ۼ‬༗ࡏ̞̾̀ͅࡉͥ͂Ȃఱܑުͬಎ૤̱͂̀ࡹဥ৽̦ྦྷ‫ۼ‬༗ࡏٛ২͂༗ࡏࠀ࿩ͬ೿̳̱ࠫͥ̈́̓̀Ȃਲު֥֓ͅၷ༗વͬ೹‫ॽ̳ͥރ‬ழ͙̦೰಍̱̞̀ͥȃ̭ͦͤ͢ͅȂ஠࣭ྦྷ͈ 6 ‫ڬ‬೾ഽ̦֓ၷ༗વͬං̞̀ͥȃু‫ުא‬৪൝͉Ȃࡢ૽́ྦྷ‫ࢫ࠲ۼ‬༗ࡏͅ‫ح‬ව̱̤̀ͤȂྦྷ‫ࢫ࠲ۼ‬༗ࡏঌા͉Ȃఱܑު̫࢜ঌાȂಎ઀ܑު̫࢜ঌાȂࡢ૽̫࢜ঌાͅఱ༆̯ͦͥȃྦྷ‫ࢫ࠲ۼ‬༗ࡏ͈ಎ͉́Ȃྦྷ‫ۼ‬༗ࡏٛ২̦֓ၷ͈΋ΑΠȂৗȂͺ·Γᾼ̞̾̀‫ۯ‬ၑ̱̠̳͂ͥ͢ζΐΐΡΉͺ͂ࡤ͊ͦͥࠁఠ͈༗ࡏ๊̦֚എ̞͂̈́̽̀ͥȃζΥΐΡΉͺ֓͜ͅၷίυΨͼΘȜ͈͒ͺ·ΓΑଷࡠ͈‫̯ͥ̓̈́͢ͅޑ‬ໝତ͈ࠁఠ̦̜ͤఉအ̜́ͥȃ! ࢖എଷഽ̜́ͥȂιΟͻΉͼΡȆιΟͻΉͺ़͈࡙͉ȂႲཆଽຸ͂ਗଽ़ຸ͈࡙̜́ͥȃਗଽຸ͂Ⴒཆଽຸ͈໦౜༹༷͉Ȃအș̈́ࠁఠ̦̜ͥȃ! ྦྷ‫ࢫ࠲ۼ‬༗ࡏ̧͈֨਋̫͉‫א‬၌͈ྦྷ‫ۼ‬༗ࡏٛ২͈͕̥͜ͅఉအ̈́৽ఘ࣐̽̀ͩͦ̀͢ͅ
̞ͥȃྦྷ‫ࢫ࠲ۼ‬༗ࡏͬड்̧̩̥ͣ֨͜਋̧̫̹̀ Blue Cross Blue Shield ͉Ȃਗౙպ́‫̞̯ͥ̀ͦא׋‬๱‫א‬၌͈ழ૕̜́ͤȂ࡛ह́͜௖؊͈ܰ࿅ͬခ̱̞̀ͥȃ̭͈͕̥͜ͅఱ
਀ྦྷ‫ۼ‬༗ࡏٛ২͂൳ܰ࿅ͬခ̳ͥ๱‫א‬၌͈ழ૕̜ͥ͜ȃ֓ၷίυΨͼΘȜ̦ྦྷ‫ࢫ࠲ۼ‬༗ࡏ̧͈֨਋̫࣐̞ͬ̽̀ͥΉȜΑ͜ఉ̞ȃܑުু૸̦ςΑ·̧ͬ֨਋̫̀ਲު֥֓ͅၷ༗વ
ͬ೹‫زু̳ͥރ‬༗ࡏ͂ࡤ͊ͦͥࠁఠ͜ఱܑުͬಎ૤ͅఉ̩ࡉͣͦͥȃ! ̭͈̠͢ͅȂༀ࣭͈ΰσΑΉͺΏΑΞθ͉Ȃྦྷ‫৽ͬۼ‬ఘ̳͂ͥఉအ̈́൚ম৪̦ంह̱ȂͼΦαȜΏοϋ̦‫ڰ‬อ࣐ͩͦͥͅΏΑΞθ̱͂̀ࠁ଼̯̞ͦ̀ͥȃ! ༀ࣭͈ΰσΑΉͺΏΑΞθ͈අಭ̱͂̀Ȃडࢃ֓ͅၷ঑੄̦ޭ͛̀ఱ̧̞̭͂ͅ૘ͦ̀
̤̩ȃༀ࣭͈֓ၷ঑੄͉Ȃచྴ࿒ GDP ๤́ 17ɓ಼̢̤ͬ̀ͤȪ2009 ාȫȂఈ͈୶ૺ࣭͂
๤‫̱̀͜ڛ‬ඏ੄̱̤̀ͤȂ̱̥͜ාș௩‫̜ͥ࢜ͅ߹ح‬ȃ̭͈̠̻࿩ 60ɓ͉Ȃ‫ࠗز‬Ȇܑު̞̹͂̽ྦྷ‫ۼ‬໐࿝̦໅౜̱̞̀ͥȃ໅౜৪͂̽̀ͅȂ֓ၷ঑੄͈௩‫ဲͬح‬ଷ̳ͥࠐफഎ̈́ͼϋΓϋΞͻή̢͉̞̞̠̭̦̞ࣞ͂͂ͥȃ̹͘Ȃༀ࣭̤̞̀͜ͅ੭șͅૺ࣐̳ͥࣞႢ‫ا‬൝ͬࡔ֦̱͂̀Ȃ࢖എ֓ၷ༗વଷഽͬ‫̳ͥא׋‬ଽຸ͈֓ၷ঑੄͜௩ఱ߹̜࢜ͥͅȃ࢖എ໐࿝̦໅౜̳ͥ֓ၷ঑੄͉ 1980 ාయࢃ฼͉ͅ 30ɓ೾ഽ̜̹̦́̽Ȃ2000 ාయࢃ฼͉ͅ 40ɓ́͘ષઌ̱̞̀ͥȃႲཆଽຸ͈ထॳͅ୸͛ͥ֓ၷ‫߸۾‬๯ဥ͜ 2010 ාထॳ͉́ 21ɓ͂̈́̽̀
̞ͥȃ࢖എ໐࿝̤̞̀֓͜ͅၷ঑੄͈௩‫ဲͬح‬ଷ̳̭̦ͥ͂ఱ̧̈́‫ه‬ఴ̞͂̈́̽̀ͥȃ! ӳུ୯͈‫ٽ‬ါ! ల 1 ડܱͅ੆̯̞̤ͦ̀ͥ͂ͤȂༀ࣭̤̞͉̀ͅ 1990 ාయͅΟͻΐȜΒȆζΥΐιϋΠ
̦อജ̱Ȃ̷͈‫ٽ‬ැȆ਀༹͉Ȃ‫͈࣭ڎ‬ΟͻΐȜΒȆζΥΐιϋΠͅఱ̧̈́‫ͬޣג‬ဓ̢̞̀ͥȃༀ࣭͈ΟͻΐȜΒȆζΥΐιϋΠ͉Ȃ࢖എଷഽ͂ྦྷ‫ۼ‬༗ࡏ̦ईࣣ̱̀֓ၷ༗વ͈ఘࠏ
ͬࠁ଼̳̞̠ͥ͂ༀ࣭͈মૂͬ෸ࠊ̱͂̀Ȃ৽̱͂̀ྦྷ‫ۼ‬༗ࡏٛ২̦‫׋‬ဥ̳͈̱ͥ͂̀͜

-20-อജ̧̱̹̀ȃ̷̱̀Ȃ̷͈ఱ̧̈́ࡔ൲ႁ̹͈͉͂̈́̽Ȃࡹဥ৽̦ਲު֥֓ͅၷ༗વͬ೹
‫ॽ̠̞̳͂ͥރ‬ழ͙͈͂͜Ȃ௩ఱ̳ͥਲު֥͈֓ၷ‫۾‬Ⴒ๯ဥ͈ဲଷͅచ̳ͥࡹဥ৽͈‫̞ޑ‬൲‫̹̜̽́ܥ‬ȃ! ̭͈̠͢ͅȂঌા৾֨ͬஜ೹̱͂̀อജ̧̱̹̀ༀ࣭͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃྦྷ‫͈֓ۼ‬ၷ༗ࡏ৪Ȃࡹဥ৽ͅनဥ̧̯̹̦ͦ̀Ȃਗଽຸ͈‫̳ͥא׋‬ιΟͻΉͼ
Ρ͜ͅनဥ̧̯̹ͦ̀ȃ̯ͣͅȂਗଽຸȂߴଽຸ̦ুஜ̜̞͉̭́ͥͦͣଽຸ͈‫׳‬੩ͬ͂͜ͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉৘ঔ̧̯̹ͦ̀ȃ̭͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬȂႲཆଽຸ͈ଽॐ̱͂̀৾ͤષ̬̹͈̦ȂιΟͻΉͺ́ 2005 ා̥ͣ৾ͤழ̹ͦ͘ΩͼυΛΠȆίυΈρθ̜́ͥȶιΟͻΉͺȆΰσΑ΍εȜΠȷ
ȪMedicare Health SupportȂո‫ ئ‬MHS ̞̠͂ȃȫ̜́ͥȃMHS ଼͈‫͉ض‬ȂΟͻΐȜΒȆζΥΐιϋΠ஠ఘ͈࢘‫̳ͥ۾ͅ଻ض‬ఱ̧݈̈́აͬৼ̱̹̞̠ܳ͂ത́͜Ȃༀ࣭͈ΟͻΐȜΒȆζΥΐιϋΠ͈൲࢜ͅఱ̧̈́‫̞̱ͥ̀ॼͬޣג‬ȃༀ࣭͈ΟͻΐȜΒȆζΥΐιϋΠ͈‫ڟ״‬Ȇ‫ٽ‬ැȆ਀༹ͅ‫͉̱̀۾‬Ȃ̳́ͅల 1 ડ̷͈́‫ٽ‬ၞ̦૘̞ͦͣͦ̀ͥȃ̹͘Ȃ̷͈મळ̞͉̾̀ͅఅ༗ΐλΩϋܱැ़౬஽੥ల 65 ࣢ͬ४ચ̞̹̺̩̭̱͂͂̀‫ڬ‬Ք̳ͥȃ̷̭́Ȃུ୯͉́ MHS ͈‫ٽ‬ါ͂ȂMHS ̦ৼ̱̹݈ܳა̞̾̀ͅ۰ౙͅત̳ٚͥ
͂͂͜ͅȂड߃͈ༀ࣭̤̫ͥͅΟͻΐȜΒȆζΥΐιϋΠ͈൲̞࢜̾̀ͅ૘̭̳ͦͥ͂͂
ͥȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟ӱ࢖എ̈́֓ၷ༗વଷഽ͈̥̈́́৾ͤழ̧̹ͦ̀͘ΟͻΐȜΒȆζΥΐιϋΠ
! ༀ࣭͉́Ȃ࢖എ̈́֓ၷ༗વଷഽ͈‫ۼྦྷͬא׋‬༗ࡏٛ২̦਋ు̳̞̠̭̦࣐ͥ͂͂ͩͦ
̧̤̀̀ͤȂ਋ు̱̹ྦྷ‫ۼ‬༗ࡏٛ২̦Ȃచય৪ͅచ̱̀ȂΟͻΐȜΒȆζΥΐιϋΠͬ೹‫ࠁ̠̞̳͂ͥރ‬ఠ́Ȃ࢖എ̈́֓ၷ༗વଷഽ͈̥̈́́͜ΟͻΐȜΒȆζΥΐιϋΠ̦৘ঔ̧̯̞ͦ̀̀ͥȃࣞႢ৪̫࢜֓ၷ༗વଷഽ̜́ͥιΟͻΉͺ̤̞͉̀ͅȂచય৪̦ȂιΟͻΉͺ͈‫৽א׋‬ఘ̜́ͥ CMSȪCenters for Medicare & Medicaid Servicesȫ̦೹‫ރ‬̳ͥίρϋ͈యͩͤͅȂྦྷ‫ۼ‬༗ࡏٛ২͈࠲ࢫ༗ࡏίρϋͬ஖఼̧̳̭̦ͥ͂́ͥȃྦྷ‫ۼ‬༗ࡏٛ২͈࠲ࢫ༗ࡏίρϋͬ஖఼̱̹చય৪͉ͅȂྦྷ‫ۼ‬༗ࡏٛ২̥ͣΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈೹‫࣐̦ͥͦͩރ‬ાࣣ̦̜ͥȃ! ̹͘Ȃ‫ڎ‬ਗ̦‫̞̱ͥ̀א׋‬೩ਫ਼ං৪̫࢜֓ၷ༗વଷഽ̜́ͥιΟͻΉͼΡ̤̞͉̀ͅȂιΟͻΉͼΡ͈‫ۼྦྷ̦א׋‬༗ࡏٛ২ͅտు̯̞ͦ̀ͥાࣣ̦̜ͤȂιΟͻΉͼΡ͈చય৪͉ȂιΟͻΉͼΡ͈‫ͬא׋‬਋ు̱̞̀ͥྦྷ‫ۼ‬༗ࡏٛ২̥ͣΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈೹‫ͬރ‬਋̫ͥȃӲιΟͻΉͺȆΰσΑ΍εȜΠ͈৘ঔ1919

ιΟͻΉͺȆΰσΑ΍εȜΠͅ‫͉̱̀۾‬ȂȶΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬ٛȷΏϋεΐ;θȶ̭̥͈ͦͣ୆‫ڰ‬ਠ‫۝‬ພచॐ͈̜༷ͤͬౝͥ! Ƚༀ࣭͈ιΟͻΉͺȂιΟͻΉͼΡ̤̫ͥͅΟͻΐȜΒȆζΥΐιϋΠȆίυΈρθ൵ව̥ͣ‫͐ڠ‬ȷȪఅ༗ΐλΩϋܱැ़౬஽੥ల 72-21-

! ༷֚ȂιΟͻΉͺ͈̥̈́́͜ȂCMS ̦‫੄̳ͥא׋‬ြࣞ໡̞༷৆͈ίρΰ͉ȂΟͻΐȜΒȆζΥΐιϋΠ͉৘ঔ̯̭̥̹̦ͦ̀̈́̽Ȃ੄ြࣞ໡̞༷৆͈ίρϋͬ஖఼̱̞̀
ͥచય৪ͅచ̱̀Ȃ2005 ා̥ͣ 2008 ා́͘ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ࡑഎͅ৘ঔ̳ͥদ͙̦࣐̹ͩͦȃ̭̦ͦȂMHS ͂ࡤ͊ͦͥΩͼυΛΠȆίυΈρθ̜́ͥȃո‫ئ‬ȂMHS ͈ඤယȂࠐً̞̾̀ͅત̳ٚͥȃȪ˝ȫιΟͻΉͺȆΰσΑ΍εȜΠ͈ඤယ! 2003 ා଼ͅၛ̱̹ιΟͻΉͺ߃య‫༹ا‬ȪMedicare Prescription Drug, Improvement
and Modernization Act of 2003ȫ͉ͅȂιΟͻΉͺ̤̫ͥ֓ͅၷ๯͈ဲଷȂ֓ၷ͈ৗ͈
٨஝͈̹͈͛‫ڎ‬ਅ৘ࡑഎίυΈρθ͈৘ঔ̦ܰ೰̱͂̀େࣺ̹ͤͦ͘ȃMHS ͉Ȃ̷͈۪̱֚͂̀Ȃྕ଻৖ۛͅᑋ̱̞ۛ̀ͥιΟͻΉͺ਋‫ݯ‬৪͈Ήͺ͈٨஝͈̹͛ͅȂΟͻΐȜΒȆζΥΐιϋΠ͈਀༹͈࢘‫࠿ͬض‬બ̳ͥ࿒എ́৘ঔ̯̹ͦȃ! ! 8 ͈̾౷֖̦஖೰̯ͦȂ‫ڎ‬౷֖̤̫ͥͅίυΈρθ͈৘ঔ͉Ȃ̷̸ͦͦ։̈́ͥ DM মު৪൝ͅտు̯̹ͦȃίυΈρθ͈చય৪͉Ȃໝତ͈ྕ଻৖ۛͬခ̳ͥۛ৪̯͂ͦȂίυΈρθ͈೹‫ͬރ‬਋̫ͥΈσȜί͂ίυΈρθ͈೹‫ͬރ‬਋̫̞̈́๤‫ڛ‬ΈσȜί͈ 2 ߲̩ͬ̾ͤρϋΘθ‫ا‬๤‫ڛ‬দࡑ͈਀༹ͤ͢ͅȂ࢘‫࠿ض‬બ̦࣐̭̹ͩͦͥ͂͂̈́̽ȃ࢘‫࠿ض‬બ͈చય͉Ȃ৽̱͂̀(a)֓ၷ͈ৗ͈࢜ષȂ(b)ۛ৪̤͍֓͢ၷίυΨͼΘȜ͈ྖ௷ഽ࢜ષȂ(c)֓ၷ๯௩‫ဲ͈ح‬ଷ͈ 3 ത̯̹͂ͦȃඅͅȂ֓ၷ๯௩‫ဲ͈ح‬ଷͅ‫͉̱̀۾‬ȂMHS ͈৘ঔฺ̠ͅ๯ဥͬȂMHS ͈৘ঔͥ֓͢ͅၷ๯௩‫ဲ͈ح‬ଷ࢘‫ํ͈ض‬սඤͅဲ̢̭̦ͥ͂࿒ດ̯̹͂ͦȃ
! ! 2005 ා̥ͣ৘ঔ̯̹ͦ MHS ͉ల 1 ‫͂ܢ‬պ౾̫̿ͣͦȂల 1 ‫̭̯ͥͦ෇ږ̦ض͈࢘ܢ‬͂ͬૄ࠯̱͂̀Ȃ̷͈ܰ࿅ͬ‫ڐ‬ఱ̱̀ల 2 ‫̦ܢ‬৘ঔ̯̭̞̹ͦͥ͂͂̈́̽̀ȃȪ˞ȫιΟͻΉͺȆΰσΑ΍εȜΠ͈ࠐً! ̭̠̱̀৘ঔ̯̹ͦ MHS ̜̹̦́̽Ȃ೰̹͛ͣͦ࿒ດͬో଼̳̭̦ͥ͂ࣾඳ̜́ͥ͂
͈ၑဇ̥ͣȂ৘ঔ‫ۼܢ‬ಎͅ 3 ౷֖̦ίυΈρθ͈ಎগͬࠨ೰̳ͥ̈́̓Ȃ৘ঔ‫ۼܢ‬ಎ̷଼̥͈ͣ๛̦‫̹̽̈́͂ޙેͥͦ͐͘ܓ‬ȃ2007 ා 7 ࠮ȂίυΈρθ‫ٳ‬ই̥ͣ 6 ώ࠮‫ض͈࢘ۼ‬࠿બ͈ࠫ‫̦ض‬ల 1 ٝ༭࣬੥̱͂̀࢖ນ̯̹ͦ20ȃల 1 ٝ༭࣬੥͉́ȂMHS ৘ঔฺ̠ͅ๯
ဥ̦Ȃ֓ၷ๯௩‫ဲ͈ح‬ଷ࢘‫ํ͈ض‬սͬఱ಼̧̢̩͈̞͈ͥ͂̈́̽̀ͥ͂ࠫ͜‫̦ض‬া̯̹ͦȃల 1 ٝ༭࣬੥͈࢖ນͤ͢ͅȂ‫߸۾‬৪͈‫͉́ۼ‬ȂMHS ̦‫ܢ‬ఞ଼̯̹ͦ‫̦͈̬̜ͥͬض‬ࣾඳ̜͈́ͥ͂෇ে̦ࢩ̦̹̽ȃ! ! ௽̞̀Ȃ2008 ා 12 ࠮ͅȂMHS ‫ٳ‬ই̥ͣ 18 ώ࠮‫࠿ض͈࢘ۼ‬બ̦ల 2 ٝ༭࣬੥̱͂̀
࢖ນ̯̹ͦ21ȃల 2 ٝ༭࣬੥͉́Ȃ֓ၷ͈ৗ͈࢜ષȂۛ৪ྖ௷ഽͬບ‫̳֚ͥث‬໐͈ঐດ́

࣢Ȃ2006 ාȫͅༀ࣭͈൚ম৪࣒ͥ͢ͅ‫׵‬঩ၳ̦ਓ჏̯̞ͦ̀ͥȃ
20 Centers for Medicare & Medicaid Services, “Evaluation of Phase I of Medicare HealthSupport (Formerly Voluntary Chronic Care Improvement) Pilot Program Under
Traditional Fee-for-Service Medicare”, 2007.
21 Centers for Medicare & Medicaid Services, “Evaluation of Phase I of the Medicare
Health Support Pilot Program Under Traditional Fee-for-Service Medicare: 18-Month-22-٨஝̦‫̦̹̯ͦ෇ږ‬Ȃ๯ဥͅ‫͉̱̀۾‬Ȃ٨͛̀ίυΈρθ͈࿒ດ̦ో଼̯̞̞ͦ̀̈́ે
‫̹̯̥ͦͣͅྶ̦ޙ‬22ȃ㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ⃻⁁ߣ᡽╷⺖㗴ӱιΟͻΉͺȆΰσΑ΍εȜΠ̦ဓ̢̹‫ޣג‬! MHS ͈࢘‫࠿ض‬બ͉ȂΟͻΐȜΒȆζΥΐιϋΠ஠ఘ͈࢘‫ͅض‬చ̳ͥࡉ༷͜ͅఱ̧̈́‫ג‬‫ͬޣ‬ဓ̢̹ȃΟͻΐȜΒȆζΥΐιϋΠ͈࢘‫̱̀۾ͅض‬๛೰എ̈́ࡉٜ͜ఉ̩া̯̹̦ͦȂ
MHS ͈࢘‫࠿ض‬બ̥ͣȂΟͻΐȜΒȆζΥΐιϋΠ͈‫ه‬ఴͬ໦ଢ଼എͅಒ੄̳ͥঐഊ͜ࡉͣ
ͦͥȃ̢̹͂͊ȂΟͻΐȜΒȆζΥΐιϋΠ̦ྦྷ‫ۼ‬༗ࡏٛ২ͤ͢ͅ৘ঔ̧̯̹̭ͦ̀͂
̥ͣȂచયۛ৪͈஖೰Ȃਹછഽ͈ບ‫ͅث‬၌ဥ̱̞̀ͥΟȜΗ̦ະ਱໦̜́ͥതȂ֓঍͈͂Ⴒࠈ̦਱໦̞́̈́തȂͬΟͻΐȜΒȆζΥΐιϋΠ̤̫ͥͅ‫ه‬ఴ̱͂̀ঐഊ̯̞ͦ̀
ͥȃ̷̱̀ȂΟͻΐȜΒȆζΥΐιϋΠ͈ౣ‫ܢ‬എ̈́֓ၷ๯௩‫ဲ͈ح‬ଷ࢘‫ࡠ͉ض‬೰എ̜́ͤȂ̷͈ࡠ‫࣪ͬٮ‬໚̳̹͈ͥ͛་‫̦ا‬ຈါ͂ঐഊ̱̞̀ͥ23ȃ! ̱̥̱Ȃջட̱͂̀ΟͻΐȜΒȆζΥΐιϋΠ͈࢘‫ض‬ȂඅͅȂ֓ၷ๯௩‫ဲ͈ح‬ଷͅచ̳ͥ‫ܢ‬ఞ̦̞̭ࣞ͂ͬা̳಺औ͜া̯̞ͦ̀ͥȃKaiser Family Foundation ̦ 2010 ාܑͅު̫࢜ͅ৘ঔ̱̹ͺϋΉȜΠ಺औ͉́Ȃٝ൞ܑ̱̹ު͈ 60%̦ȶΟͻΐȜΒȆζΥΐιϋΠ͉Ȃ֓ၷ๯௩‫ဲ͈ح‬ଷ࢘‫̢ͥࣉ̜̦͂ͥض‬ȷ̱̞͂̀ͥȃӲༀ࣭̤̫ͥͅड߃͈ྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθ͈൲࢜! ༀ࣭͈ྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡ͈ႀ֖͈අಭ͉Ȃအș̈́κΟσ̦৘षͅদ࣐̯ͦȂκΟσ൳আ̦‫އ‬௔̱Ȃ̷̭̥ͣͼΦαȜΞͻή̈́κΟσ̦୆͙੄̯̭̜ͦͥ͂ͧͥͅȃ
2000 ාయͅවͤȂ૖֖̤̫ͥͅ࠲ࢫ௩ૺ͈৾ழ̦;ͿσΥΑȆίυΈρθ͂ࡤ͊ͦ̀ಕ
࿒ͬਬ̷̞͈͈͛̀ͥ͜ 1 ̢̞̾͂ͥȃ;ͿσΥΑȆίυΈρθ͉Ȃ֓ၷ๯௩‫ဲ͈ح‬ଷ̺̫̩́̈́ȂႻ൱୆ॲ଻ͅచ̱̀͜ઙതͬ൚̞͈̦̀̀ͥඅಭ̜́ͥȃ̹͘Ȃ2000 ාయ੝൮̥ͣ೹੹̧̯̹ͦ̀ Population Health Management ͬ৘கഎͅ൵වܑ̳ͥުȂমު৪̧࡛̞ͩͦ̀̀ͥ͜ȃPopulation Health Management ͉Ȃਬ౬ͅచ̱̀Ȃྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພۛ৪ͅచ̳ͥΟͻΐȜΒȆζΥΐιϋΠȂ࠲ࢫ̈́૽ͬ͜చય̱̹ͅ;ͿσΥΑȆίυΈρθȂਹછۛ৪ͅచ̳ͥΉȜΑȆζΥΐιϋΠ̈́̓ໝତ͈ίυΈρθͬൡࣣഎͅ೹‫̭̳ͤ͂ͥ͢ͅރ‬Ȃਬ౬஠ఘ͈࠲ࢫഽͬ࢜ષ̵̯Ȃ֓ၷ๯௩‫ဲ͈ح‬ଷȂႻ൱୆ॲ଻͈࢜ષͬ৘࡛̱̠̳͂ͥ͢‫ٽ‬ැ̜́ͥȃ! ྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθͅ‫̱̀͜۾‬ȂPatent Centered Medical HomeȪո‫ئ‬ȂȶPCMHȷȫ͂ࡤ͊ͦͥ‫ٽ‬ැ͈͒‫۾‬૤̦̞ࣞ̽̀ͥ͘ȃPCMH ͉͂Ḁ̥̫̦̑ͤ̾֓
ྕ଻৖ۛۛ৪͈হၷͅ஠๊എ̈́ୣහͬ঵̻Ḁ̥̫̦̑ͤ̾֓‫ܖ‬ത̦͂̈́ͤ̈́ͣ୺࿝֓ȂInterim Analysis October 2008”, 2008.
ల 1 ٝ༭࣬੥Ȃల 2 ٝ༭࣬੥͉ಎ‫ۼ‬༭̜࣬́ͤȂ৘ঔ‫ͬۼܢ‬೒̲̹࢘‫࠿ض‬બͅ‫̱̀۾‬ల 3 ٝ༭࣬੥̦࢖ນْ̯̞̹̦ͦͥࠗ͂̈́̽̀Ȃల 3 ٝ༭࣬੥͉࢖ນ̯̞̞ͦ̀̈́ȃ
23 Ariel Linden and Julia Adler-Milstein, “Medicare Disease Management in Policy
Context”, Health Care Financing Review, Spring 2008, 29(3)1-11.
22

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ພ̷͈֭ఈ͈֓ၷ୺࿝૖͂Ⴒࠈͬ଎̦ͤ̈́ͣࠑ௽എ̈́হၷͬ೹‫̳ͥރ‬κΟσ̜́ͥḁ̥̫̑ͤ̾֓͂ۛ৪͈‫ͬ߸۾‬ਹণ̱Ȃۛ৪͈ুࡨ‫ۯ‬ၑෝႁ͈‫৽̦اޑ‬ါ̈́ါள̞͂̈́̽̀
ͥȃࡢș͈৖͉̩ۛ́̈́Ȃۛ৪͈છે஠๊ͅઙതͬ൚̹̀হၷȂ‫ۯ‬ၑͬ࿒ດ̱̞͂̀ͥȃ̭͈̠͢ͅȂༀ࣭̤̞͉̀ͅȂྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθͅ‫̱̀۾‬Ȃ૧̱̞൲̦࢜ࡉͣͦͥȃ
ӳ2010 ාΰσΑΉͺ٨‫଻ྕ༹̫̤ͥͅڟ‬৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡίυΈρθ͈պ౾̫̿
! 2010 ා଼ͅၛ̱̹ΰσΑΉͺ٨‫༹ڟ‬ȪThe Patient Protection and Affordable Care
Act of 2010 ȫ ͅ ͉ Ȃ ΰ σ Α Ή ͺ ͈ ຦ ৗ ࢜ ષ ͬ ଎ ͥ ଽ ॐ ͈ ֚ ۪ ͂ ̱ ̀ Ȃ ৖ ພ ထ ཡȪPreventionȫ͂࠲ࢫ௩ૺȪWellnessȫͅ‫̳ܰͥ۾‬೰̦୭̫̞ͣͦ̀ͥȃ̭͈̥͉̈́ͅȂ৖ພထཡȂ࠲ࢫ௩ૺ̤͍͢࢖ਤ‫מ‬୆‫ڰ‬൲͈ଔૺͬ࿒എ̳͂ͥ૧̹̈́ଽຸ‫͈۾ܥ‬஻୭ȂιΟͻΉͺ̤̫ͥͅထཡ΍ȜΫΑ͈ুࡨ໅౜͈ക෱Ȃ࠲ࢫ௩ૺచॐ৾ͤͅழ͚ಎ઀ܑު͒
͈੩଼߄ଷഽ͈஻୭̦̈́̓େࣺ̞ͤͦ̀ͥ͘ȃྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡ̤̫ͥͅଽॐ
τασ͈‫۾‬૤͉Ȃਹછ‫ا‬ထཡ̥ͣอછထཡȂ࠲ࢫ௩ૺ̷͈͒ํսͬࢩ̬̞̀ͥȃ̭͉ͦͣȂྕ଻৖ۛͅ‫̳ͥ۾‬ထཡ঑‫ڰ׳‬൲ͬႲཆଽ़ຸ͈࡙໅౜́৘ঔ̳ͥଽॐ̜́ͥȃ! Ӵ֓ၷ༗ࡏ৪൝̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ດ੔௡๵‫ا‬! ! ൵ව൚শ̷͈֓ͅၷ๯ॉࡘ࢘‫̦ض‬ఱ̧̩࠶ഥ̯ͦȂ୯ࡘͬ༗બ̳ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔࠀ࿩͜େ࣐̱̹̦Ȃ̷͈ࢃ୯ࡘ࢘‫༹݈̞༷̀̾ͅ௶͈ࠗض‬ა̦ୟ͙ਹ͇ͣͦȂίυΈρθ৘ঔͅջͥ୯ࡘ࢘‫ͅྟࡕͬض‬ၛબ̳̭̦ͥ͂ࣾඳ̜̭́ͥ͂
̦฻ྶ̱̞̹̀̽ȃ̱̥̱ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉చયਬ౬͈࠲ࢫςΑ·͈٨஝͈̈́̓࢘‫ވ͉̭̜̦͂ͥض‬೒෇ে̤͂̈́̽̀ͤȂ࡛শത̳́́ͅఉ̩͈֓ၷ
༗ࡏ৪Ȫࡹဥ৽͈ু‫ز‬༗ࡏͬ‫͚܄‬ȫ́೒ુ͈΍ȜΫΑ̱͂̀नဥ̯̞ͦ̀ͥȃ̷͈փྙ͉́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃඅ༆ͅ਀෻̧̳͓͈͉̩́̈́͜Ȃ֓ၷ༗ࡏ̤̫ͥͅດ੔എ̈́௡๵̢̹̞̈́̽͂ͥ͜ͅȃ̤̈́Ȃల 1 ડ́৾ͤષ̬̹Ȃcare
management ͉Ȃ”disease management”͂ࡤઠ̯ͦ̀Ȃఉ̩͈ા࿂́၌ဥ̯̞ͦ̀ͥȃӵਗଽຸ൝͈ఉအ̈́৾ழ͈ࠑ௽
MHS ͈࢘‫࠿ض‬બ̦̯̹̈́ͦࢃ͜Ȃྕ଻৖͈ۛထཡ঑‫͉׳‬ਹါ̈́ଽॐ‫ه‬ఴ̜́ͤ௽̫̀
̞ͥȃ̭͈̹͛Ȃਗଽຸ൝ͥ͢ͅȂ̯̰̈́͘͘ྕ଻৖ۛచॐ͈ΟͻΐȜΒȆζΥΐιϋ
Π͈৾ழ͉ࠑ௽̱̞̀ͥȃਗଽຸ൝͈ड߃͈৾ழͬ໦ଢ଼̱ત̱̹ٚ੥ୠ̦‫̞̯࣐̀ͦۏ‬ͥ 24 ȃအș̈́৾ழͬȂ႕̢͊ȂFully integrated modelsȂCommunity-based sociallyoriented modelȂ Patient-Centered Medical Homes ̱̈́̓͂̀ାၑ໦ଢ଼̱̞̀ͥȃ̭͈ͦͣκΟσ͉Ȃcare coordination ฺ̠ͬίυΈρθ̜́ͥȃ൳੥͉Ȃ࢘‫ض‬എ̈́ΉͺȆ΋ȜΟͻΥȜΏοϋȪcare coordinationȫͬ৘࡛̳ͥٚවίυΓΑͬυΐΛ·ȆκΟσȪLogic Modelȫ́া̱̞̀ͥȪ଎ນ 2-2-1 ४ચȫ25ȃυΐΛ·ȆκΟσ͉ȂͼϋίΛΠ
24

Schraeder C and Paul Shelton eds., “Comprehensive care coordination for chronicallyill adults”, 2011 .

Brown S et al, “Promising practices in acute/primary care”, in Schraeder C and Paul
Shelton eds., “Comprehensive care coordination for chronically ill adults”, 2011 .

25

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̦̯̈́ͦȂੜၑ‫ڰ‬൲ίυΓΑ̦৘࣐̯ͦȂ̷͈ࠫ‫ض‬ͺ;ΠίΛΠ̦ॲ੄̯ͦȂͺ;Π΃
θ̦ࠗ௶̯֚ͦͥႲ͈ࢥ೾̞̾̀ͅȂါள̷͈͂‫ͬ߸۾‬଎ٜ̳͈̜ͥ́ͥ͜ȃ̭͈଎ນ͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈‫ུܖ‬എ̈́ίυΓΑͬୈᣰͅାၑ̱ೄ̱̹͜
͈̜́ͥ͂ၑ̧ٜ́ͥȃ࿑⴫ 2-2-1

Program Featuresand Enrollment

Program Context(e.g., host organization type,care coordinator background,caseload size, pre-existing
relations with physicians)
Approaches to Care
Coordination(e.g., assessment, careplanning, monitoring,education, communication withphysicians, managing
transitions, medication
management, service andresource arranging)
Care manager contact typeand intensity

Target population of
beneficiaries
Recruitment
Enrollment

Logic Model for Care Coordination Interventions

Process Measures

Adherence and Quality-Related
Outcome Measures

Increased general preventive
services(e.g., colon cancer screening)High global satisfaction with
program services

Improved functioning andhealth related quality of life

Increased recommended
disease-specific services(e.g. eye examinations fordiabetes, blood tests for lipids
for diabetes and CAD)

Increased satisfaction with andreports of specific services(e.g., arranging payment fornoncovered services ormedications, helping makeappointments with specialists
or therapy services)

Decrease in potentiallypreventable hospitalizations
and complications (general anddisease-specific), decrease in
hospital readmissions

Medication management(e.g. reduced polypharmacy)
Other health care processes-Increasing adherence toguidelines-Increasing patient andcaregiver activation-More timely alerts ofpatient deterioration-Closer monitoring andfollow-up of patients-Increased communication
across providers-Improved care transitions-Increased patient education-Improved end-of-life planning

Increased patient knowledge
and adherence

Cost and Use
Outcome Measures

Reduction in Medicare service
use and cost

Decrease in mortalityȪ੄ങȫBrown S et al, “Promising practices in acute/primary care”, in Schraeder C andPaul Shelton eds., “Comprehensive care coordination for chronically ill adults”, 2011-25-╙  ▵ ࠝ࡯ࠬ࠻࡜࡝ࠕ
㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊! ӱ࣭͈අಭȆ‫ڟ״‬΂ȜΑΠρςͺႲཆȪCommonwealth of Australiaȃո‫ئ‬ȶ΂ȜΑΠρςͺȷ̞̠͂ȃȫ͉Ȃࢩํ࣭̈́ാͬခ̳ͥఉྦྷ௼࣭‫̜ͥ́ز‬ȃ૽࢛͉Ȃ࿩ 2,215 ྔ૽Ȫ2009 ා 12 ࠮ȫȃ
1901 ා‫࣭ם‬૒ྦྷ౷̥ͣඊၛ̱̹̦Ȃ‫ם‬Ⴒཆͅ௺̱̞̀ͥȃႲཆଷȪ6 ͈̾ਗ͂ 2 ͈̾අ༆౷֖ȫ̤ͬ৾̽̀ͤȂਗ͉Ⴒཆͅտો̱̹ࡀෝո‫ࡀ͈͓̳̀ͅٸ‬ෝͬခ̳ͥȃႲཆ͈ၛ༹ࡀࡠ͉Ȃ࠻༹࣭ͤ͢ͅཡȂ‫࢐ٸ‬Ȃ೒੸Ȃற୕Ȃ೒‫ى‬Ȃ֊ྦྷ൝͈අ೰͈মࣜͅ
ࡠ೰̯̤ͦ̀ͤȂ̷͈ఈ͉ਗ͈ࡀࡠ̜́ͥȃӲΰσΑΉͺΏΑΞθ͈අಭȪ೹‫ރ‬ఘଷ़࡙͂಺ో༹༷ȫͅ‫̳ͥ۾‬ଽॐ͈་஗࡛͂ે
΂ȜΑΠρςͺ͉́Ȃଽࡀ͈་஗̦ΰσΑΉͺΏΑΞθ͈་ࢵ̧̹̱̹ͬͣ̀͜ȃలඵষఱ୽ࢃȂႻ൱ൂଽࡀ͉ȂႲཆͅ࿪सȆ৖ພȆພ֭ͅ‫ͬࡠࡀ̠࣐ͬັݯ̳ͥ۾‬ဓ̢ͥ࠻༹ਘୃ࣐ͬ̽̀‫ ͈࣭ם‬National Health Service(NHS)ͅ༩̹̽ଷഽͬ൵ව̱̠̱͂͢
̹ȃ̱̥̱Ȃ֓ၷ‫߸۾‬৪͉̭͈ଷഽ͉́‫ݯ‬ဓଷ͂̈́ͤਓවͅષࡠͬ୭̫̭ͥ͂̈́ͥ͂ͅ
̱̀฽చ̱Ȃ̯ͣͅুဇൂ͂౷༷ൂ͈฽చ̜̽̀͜Ȃ̭͈ࢹே͉৘࡛̱̥̹̈́̽ȃ̷͈ࢃȂຫࣾ৪൝͈͒֓ၷ༗વଷഽ͉൵ව̯̹͈͈ͦ͜Ȃ࣭ྦྷ͉Ȃজ๯૷ၷ̱͂̀ুဇ૷ၷ
଻̜́ͥ֓ၷ΍ȜΫΑͬ਋̫Ȃྦྷ‫֓ۼ‬ၷ༗ࡏͅ‫ح‬ව̳ͥຈါ̦̜̹̽ȃ1960 ාయࢃ฼͈
শത͉́Ȃ࿩ 17ɓ̦ྫ༗ࡏ৪̜̹͈́̽͂ଔ̯̞ࠗ̈́ͦ̀ͥ͜26ȃ
1972 ාႻ൱ൂଽࡀ͂̈́̽̀Ȃ1974 ා࣭ͅྦྷ࠲ࢫ༗ࡏଷഽ͂̈́ͥȶιΟͻΨϋ·
ȪMedibankȫȷͬ‫ ̳ͥא׋‬Health Insurance Commission ͬ୭౾̱̹̦Ȃံ 1975 ා͉ͅ༗৿ࠏ͈ুဇൂȆ࣭ྦྷ౷༷ൂႲၛଽࡀͅଽࡀ̦࢐య̱̹ȃুဇൂȆ࣭ྦྷ౷༷ൂႲၛଽ
ࡀ͉Ȃ஠࣭ྦྷͬచય̱͂අ༆୕़࡙̳ͬ͂ͥ Medibank (Standard)ͬ஻୭̳ͥ͂͂͜ͅȂ֓ၷ༗ࡏঌા͈‫އ‬௔௯ૺ͈̹͛ͅଽຸ‫ ۾ܥ‬Health Insurance Commission ̦ਫ਼ခ̳ͥྦྷ
‫ۼ‬༗ࡏٛ২ Medibank Private ͬ୭ၛ̱̹ȃ൳Ⴒၛଽࡀ͉Ȃ1978 ාͅ Medibank(Standard)ͬ෱গ̱ȂMedibank Private ͬం௽̵̯̹ȃ
1983 ාͅႻ൱ൂଽࡀ̈́ͤͅȂ1984 ාຽ༑എ̈́֓ၷ༗વଷഽ̜́ͥȶιΟͻΉͺȪMedicareȫȷ27̦৘ঔ̯̹ͦȃ̭͈ιΟͻΉͺ͉Ȃ1996 ා༗৿ࠏ͈Ⴒࣣଽࡀͅଽࡀ࢐య
̱̹ࢃȂ̹͘ 2007 ාႻ൱ൂଽࡀͅ࢐య̱̹ࢃࣽ͜඾́͘֋঵̯̞ͦ̀ͥȃ! ! ΰσΑΉͺ೹‫ރ‬ఘଷ͈ಎ‫͉ړ‬ȂιΟͻΉͺ̜́ͥȃ1984 ාͅ஻୭̯̹ͦιΟͻΉͺଷഽ͉Ȃ࣭ྦྷ஠๊ͬచય̱̹͂Ⴒཆଽຸ͈֓ၷ༗વଷഽ́ȂႲཆଷഽͥ֓͢ͅၷ๯͈֚೰
‫͈ࣣڬ‬঑‫ݯ‬ȪιΟͻΉͺ‫ັݯ‬ȫ͂Ȃ࢖ၛພ͈֭ව֭๯ဥ͈஠‫࢖ڣ‬๯໅౜ͬ 2 ུ͈ಔ̱͂
̞̀ͥȃ‫ັݯ‬ඤယ͉Ȃ‫ٸ‬ြ͈ાࣣȂ֓ၷ๯̱͂̀ଽຸ͈೰͛ͥ૷ၷ༭ਫນ̜ͥܰͅ೰ၳ
߄͈ 85ɓ̦ιΟͻΉͺ‫̱̀͂ັݯ‬঑‫̯ͦݯ‬Ȃॼ͈ͤ 15ɓ̦၌ဥ৪͈ুࡨ໅౜͂̈́ͥȪ̈́

26

Wills et al.,“Understanding Australian Health Care System”, 2009, pp.8-9.

27ུ୯͉́ȂౙͅιΟͻΉͺ͂ນܱ̳ͥȃༀ࣭͈ιΟͻΉͺ͉͂։̈́ͥതͅၣփ̳ͥຈါ̦̜
ͥȃ

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̤Ȃ1 ͈ٝ૷ၷ̧̾ͅȂ57.50 ࣧΡσ̦၌ဥ৪͈জ๯໅౜͈ષࡠȫ28ȃ
! ! ֓ၷঔ୭̱͉͂̀Ȃ࢖എພ֭Ȫਗ̥͈ͣ༞੩ͬ਋̫ͥພ֭ȃਗ̽̀͢ͅॽழ͙̦։̈́
ͥȫȂজഎພ֭Ȫਗ̥͈ͣ༞੩ͬ਋̫̞̈́ພ֭ȃ৽̱͂̀ਕ‫ޗ‬౬ఘ͞঴஝౬ఘ̽̀͢ͅ‫׋‬‫̯ͦא‬Ȃ઀ܰ࿅͈͈̦͜ఉ̞ȫ൝̦̜ͥȃ୭౾‫͉خݺ‬ਗ͈ࡀࡠ̜́ͤȂ̷͈‫ܖ‬੔͉ਗ̽̀͢ͅ։̈́ͥȃ֓ၷਲম৪̱͉͂̀֓঍Ȃۭࢌ঍൝ࣣࠗ 24 ͈֓ၷ‫۾‬Ⴒ୺࿝૖ਅ̦ంह̳
̦ͥȂ̷͈྾‫ݺ‬ଷഽ͉ਗ͈ࡀࡠ̜́ͤȂ঩‫ڒ‬ါ࠯͉ਗ̮͂ͅ։̈́ͥȃ֓঍͉ȂίρͼζςΉͺ࣐̠ͬ GPȪGeneral Practitionerȫ͂ GP ̥͈ͣતٚۛ৪ͬ
૷ၷ̳ͥ୺࿝֓ͅ໦̫ͣͦͥȃGP ͅड੝͈౲‫૷́ٴ‬ၷͬ਋̫Ȃ̷͈ࢃຈါͅ؊̲̀୺࿝
͈֓૷ၷͬ਋̫̞̠ͥ͂Ȃ̞ͩͥ͠તٚଷഽ(referral system)̦̞৾ͣͦ̀ͥȃ! ! ֓ၷ೹‫͉́ރ‬Ȃྦྷ‫ۼ‬໐࿝̜́ͥ GP ̦৽ఘ̜́ͤȂພ͉֭࢖എ໐࿝̦౜̠ఘଷ͂̈́̽̀
̞ͥȃGP ͉Ȃ֓ၷ΍ȜΫΑঌા̤̞̀ͅ‫ুͬڒث‬໦́ࠨ̧̭̦̦͛ͥ͂́ͥȂ৘ष͉ͅιΟͻΉͺ̥͈ͣੲ‫͈ڒث̦ۺ‬ఱ̧̈́ࠨ೰ါள̞͂̈́̽̀ͥȃႤঃഎ͉ͅȂুဇ̈́৾֨
̦ஜ೹̞̥͂̈́̽̀ͥ̈́Ȃ౷֖͈֓঍̦ٛ౷֖ඤ̤̫ͥ֓ͅၷ΍ȜΫΑ‫ࠨ͈ڒث‬೰ͅ৘ৗષ‫۾‬ဓ̧̱̹̦̀Ȃ1984 ාιΟͻΉͺ൵වոࣛȂ̷͈‫ࠨڒث‬೰ႁ͉৻̹̽͘ȃιΟͻΉͺ̤̞͉̀ͅȂGP ̦࣐̠֓ၷ΍ȜΫΑ͈͒ੲ‫༹͈༷֚ۺ‬໐̱͂̀૷ၷ༭ਫນ Medical
Benefit Scheme (ո‫ئ‬ȂMBS ̞̠͂)̦೰̞͛ͣͦ̀ͥȃιΟͻΉͺͅచ̱̀ੲ‫਀ۺ‬௽ͬȂۛ৪̩́̈́ GP ̦࣐̠ Bulk Billing ༷৆͂ࡤ͊ͦͥೄ୪ੲ‫਀ۺ‬௽̦ࢩ̩नဥ̯̠ͦͥ͢
̈́ͥ͂ͅȂGP ̤͍͢౷֖֓঍͈ٛ‫ࠨڒث‬೰ႁ͉৘ৗષ‫ܥ‬ෝ̱̞͈̹̈́͂̈́̽͜ȃMBS͈ੲ‫༷ۺ‬৆͈୭͉ࠗȂGP ͈ͼϋΓϋΞͻήࠁ଼ͅࠨ೰എ̈́ਹါ଻ͬခ̳̭̹ͥ͂̈́̽ͅȃ! ! ΰσΑΉͺ़࡙಺ో༷৆ͅ‫̱̀۾‬ȂιΟͻΉͺ͉ఱ̧̈́‫ޣג‬ႁͬ঵̹̽ȃιΟͻΉͺ൵වոஜ͉၌ဥ৪͈জ๯໅౜͂ྦྷ‫֓ۼ‬ၷ༗ࡏ̦ಎ૤̜̹̦́̽ȂιΟͻΉͺ൵වࢃ͉Ⴒ
ཆଽຸͥ͢ͅ࿒എ୕़๊̤͍࡙̦֚͢৽ఘ̹͂̈́̽ȃ़़๊࡙͉࡙֚͂ιΟͻΉͺ୕Ȫࡢ૽‫୕ه‬ਫ਼ං͈ 1.5ɓȃιΟͻΉͺ‫۾‬Ⴒ঑੄͈࿩ 25ɓͬ୸͛ͥȫ̜́ͥȃਗၛພ͈֭ાࣣ
͉ͅਗଽ̷ຸ̦͈‫א׋‬๯ဥ͈ఉ̩ͬ໦౜̱̞̀ͥȃႲཆଽຸ͂ਗଽຸ͉Ȃ5 ා̮͂ͅAustralian Health Care Agreements ͬ೿̱ࠫȂႲཆଽຸ͂ਗ̦౷֖ͅచ̱̀ྫੲ͈ພ
֭΍ȜΫΑͬ೹‫̳ͥރ‬๯ဥͬ༞੩̱̞̀ͥȃ! ! ΂ȜΑΠρςͺ̤̫ͥͅΰσΑΉͺΏΑΞθ͈අಭ͈͉͌͂̾ȂႲཆ͂ਗ͈ਹ௄଻́
̜ͥȃ֓ၷ༗࠲΍ȜΫΑ͉Ȃ‫ུܖ‬എ͉ͅਗ͈‫ڵۯ‬মࣜ̈́ͥͅȃ̱̥̱ȂႲཆ͉Ȃற୕ͬࡓͅਗͅచ̱࢐ັ߄Ȇ༞੩߄ͬ‫̭̳͂ͥ͞ັݯ‬Ⴒཆτασ͈ଽॐၛմͬജ‫̭̩̞̱̀ٳ‬͂ͬ೒̱̀Ȃ֓ၷ༗࠲΍ȜΫΑ໦࿤ͅ‫ޑ‬ఱ̈́‫ޣג‬ႁͬခ̱̞̀ͥȃਲ̽̀Ȃਗଽຸ̦֚
ࡓഎͅଽॐͬ৘ঔ̧̳̭͉̞ͥ͂́̈́ȃ࡛ે͉Ȃඵ͈̾τασ͈ଽຸ̦ਹ௄̳ͥࢹ௮ͅ
28! ̹̺̱Ȃ2005 ාͤ͢ GPȪ๊֚‫֓ުٳ‬ȫͥ͢ͅ૷ၷͅ߸ͥ֓ၷ๯̞͉̾̀ͅ 100ɓιΟͻΉͺ‫ັݯ‬Ȫ၌ဥ৪͈জ๯໅౜Δυȫ̹͂̈́̽ȃ࢖ၛພ֭ͅව͈֭ાࣣ͜Ȃ֓ၷ๯Ȃພ֭๯ဥȪαΛΡయȂۭࢌၳȫ͈̈́̓ව֭ͅ߸̳͓͈ͥ̀๯ဥ̦࢖๯ͤ͢ͅ໅౜̯ͦȂ၌ဥ৪͈জ๯໅౜͉̞̈́ȃ̹̺̱Ȃ࢖ၛພ֭́͜
ۛ৪̦ুͣঐྴ̱̹֓঍̥ͣ૷ၷͬ਋̫ͥાࣣȂ֓ၷ๯͈ 25ɓ̦၌ဥ৪͈জ๯໅౜͂̈́ͤȂພ֭๯ဥ͉
‫͈ັݯ‬చય̞͂̈́ͣ̈́ȃ2004 ාͅ൵ව̯̹ͦ֓ၷ๯ΓȜέΞͻȆΥΛΠଷഽͤ͢ͅȂ֓ၷ๯̤̫ͥۛͅ
৪͈၌ဥ৪͈জ๯໅౜‫̦ڣ‬ා‫֚́ۼ‬೰‫಼̢̹ͬڣ‬ાࣣͅȂ̷ͦո͈ࣛ၌ဥ৪͈জ๯໅౜‫ ͈ڣ‬8 ‫ͬڬ‬ଽຸ̦໅౜̳ͥȃ֚೰‫͈ڣ‬ષࡠ͉Ȃා‫ ۼ‬1,000 ࣧΡσȪා߄୆‫ڰ‬৪൝೩ਫ਼ං৪͉ා‫ ۼ‬500 ࣧΡσȫ̜́ͥȃ
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̞̈́̽̀ͥȃ̷͈ࡀࡠ͈໦౜͉ո‫̞̯̤͈ͥ̀ͦ͂ͤ͂ئ‬ȃႲཆଽຸ͉Ȃ֓ၷଽॐࠁ଼ȂΰσΑς΍ȜΙ ̤͍͢࢖ਤ‫מ‬୆Ȇૂ༭ΏΑΞθ͈࿚ఴ৾ͅழȂਗଽຸ͉Ȃ‫͂ܢ଻ݢ‬ୈ૰֓ၷ͈ພ֭΍ȜΫΑͬ೹‫̥͕̳ͥރ‬Ȃ‫ࢷڠ‬༗࠲Ȃළິ঱ൺ൝͈࢖ਤ‫מ‬୆ͬ౜൚̱Ȃ֓ၷ୺࿝‫ز‬Ȇ֓ၷ‫۬ͬ۾ܥ‬ආ̳ͥȃਗଽຸ͉ࢩํ̈́ΰσΑΉͺ΍ȜΫΑ़͈࡙ͬ໅౜̱ȂႲཆଽຸ͉ພ֭΍ȜΫΑ͂ΰσΑς΍ȜΙ़͈࡙ͬ໅౜̳ͥȃႲཆଽຸ͂ਗଽຸ͉Ȃ࢖ၛພ֭͂ࣞႢ৪વ‫ٺ‬৪໛ছ़͈࡙ͬ‫ވ‬൳́໅౜̳ͥȃࣞႢ৪͈͒ΰσΑΉͺ΍ȜΫΑ͉ȂႲཆଽຸȆਗଽຸȆྦྷ‫ۼ‬໐࿝़̦࡙ͬ໅౜̱Ȃ‫ۯ‬ၑ̱Ȃ೹‫̳ͥރ‬ȃίρͼζςΉͺ̷͈͂‫۾‬Ⴒ͈Ήͺ़͈ଽ໅౜ͅ‫̱̀۾‬ȂႲཆ̦໅౜̳ͥ GP ͅ‫ͥͩ۾‬๯ဥ͂Ȃ
ਗ̦ Community
health services29ͅ໅౜̳ͥ๯ဥ̦͕͖͂൳‫̜ͥ́ڣ‬Ȫ଎ນ 2-3-1 ४ચȫȃ࿑ ⴫ 2-3-1 Expenditure on primary health care and related services, Australia,
2007-08 ($million)
ServiceCommonwealthgovernment

GP services

4394

Community
health services
and othermiscellaneous
services

635

Other healthpractitioners

1041

Dental services

645

Aids andappliances
PatienttransportStateand local
governments

Healthinsurance

Individuals

Other

Total

4812

418
1

239

69

5195

446

1574

312

3373

580

927

3944

10

6106

480

325

2264

45

252

1296

128

258

4251

3114
69

2003

Data source: AIHW 2010cȪ੄ങȫDuckett S and Sharon Willcox, “The Australian Health Care System”, 4th ed.
Oxford University Press 2011! p.162.
! ! ༆͈අಭ̱͂̀Ȃඅ։̈́࢖জईࣣΏΑΞθ̦̜̬̞ͣͦ̀ͥȃષ੆͈ଽࡀ࢐యͥ͢ͅ
་஗͈ࠫ‫ض‬Ȃ΂ȜΑΠρςͺ͉ͅȂඊু͈࢖জईࣣΏΑΞθ̦ࠁ଼̯̭̹ͦͥ͂̈́̽ͅȃ
1997 ාྦྷ‫ۼ‬༗ࡏٛ২ Medibank Private ͉ȂHealth Insurance Commission ̥ͣ໦ၗ̯ͦȂံ 1998 ාଽຸ̦ౙ֚‫ ͥ̈́͂৽ڼ‬Government Business Enterprise ̹̈́̽ͅȃ΂ȜΑΠρςͺ͈ྦྷ‫֓ۼ‬ၷ༗ࡏঌા͉ઁତ༗ࡏٛ২ͥ͢ͅ‫୸س‬ঌા̤͂̈́̽̀ͤḀ̑̈́́͜ȂMedibank Private ͉࿩ 30ɓ͈ঌા୸ခၚ̞͂̈́̽̀ͥȃ1999 ාྦྷ‫֓ۼ‬ၷ༗ࡏ௯ૺ
͈̹͛ͅȂুဇൂȆ࣭ྦྷ౷༷ൂႲၛଽࡀ͉Ȃଽຸͥ͢ͅȂ30ɓ͈༗ࡏၳ༞੩ଷഽ(rebate)౷֖͈਑ါͅ؊̲̹ఉအ̈́ΰσΑΉͺ΍ȜΫΑ̞̠ͬȃ႕̢͊Ȃcommunity nursingȂ
mental healthȂdieteticsȂၑ‫ڠ‬ၷ༹Ȃ௷ພহၷ,࡞ࢊၷ༹Ȃैުၷ༹Ȃ࠲ࢫ௩ૺ̜̈́̓́ͥȃ
29!

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ͬ൵ව̱̹ȃ̯ͣͅȂ2005 ා͉ͅ 65 पոષ͉ 35ɓȂ70 पոષ͉ 40ɓ̧֨ͅષ̬̹ȃ! ӳ࡛࣐ΏΑΞθ̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ৘ঔࠁఠ! ! ! ΂ȜΑΠρςͺ̤̞͉̀ͅȂίρͼζςΉͺ͈ႀ֖̦Ȃඵষ֓ၷ͂ྶ‫ߊͅږ‬໦̯ͦΏΑΞθ̦ழ͙ၛ̞̀ͣͦ̀ͥȃίρͼζςΉͺ̤̞͉̀ͅȂGP ̤͍͢ႲཆȆਗଽຸ̦৽̹ͥ൚ম৪̜́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐ͉Ȃ࡛࣐ΏΑΞθ͉́৽ͅίρͼζςΉͺ͈ႀ֖́ജ‫̭̯ͥ̈́͂ͥͦͅٳ‬ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈৘ঔࠁఠͬȂల 1 ડ͈଎ນ 1-3 ΟͻΐȜΒζΥΐιϋΠȆίυΈρθଽॐ͈൚ম৪́ঀဥ̱̹Ȃ൚ম৪༆ͅାၑ̳ͥ͂Ȃষ͈̤͂ͤ
͂̈́ͥȃ̳̻̈́ͩȂْࠗၛմ৪Ȇ๯ဥ໅౜৪͉ȂႲཆଽຸȆਗଽຸ̜́ͤȂ̹͘ྦྷ‫֓ۼ‬ၷ༗ࡏ৪͜වͥȃ঑‫׳‬ٚව৪ȆίυΈρθ৘ঔ৪͉ȂGP ̜́ͤȂਗଽຸ͈૖֥൝Ȃ̤͍͢ྦྷ‫֓ۼ‬ၷ༗ࡏ৪Ȫ̷͈‫ٸ‬໐տు୶ȫ̜́ͥȃ! ! ଽຸ໐࿝͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈৘ঔࠁఠ̱͉͂̀Ȃ͉͌͂̾ιΟͻΉͺచય৪ͅ‫ ̳ͥ۾‬GP ͈৾ழ̜́ͤȂ̠͉͌͂̾͜ਗ͈ਯྦྷͅ‫̳ͥ۾‬ਗଽຸ͈ͼΣΏͺΞͻήȪ٨஝৾ழȫ̜́ͥȃྦྷ‫ۼ‬༗ࡏ໐࿝͈৘ঔࠁఠ͉Ȃ༗ࡏ‫ح‬ව৪ͅ‫̳ͥ۾‬ΟͻΐȜΒȆζΥΐιϋΠ͈৾ழ̜́ͥȃ! ! Ⴒཆଽຸ͈ιΟͻΉͺ໐࿝̱͉͂̀ȂGP ̦ྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພထཡ‫ڰ‬൲࣐̠̠ͬ͢
ͅ঩߄ͬဥփ̱Ȃ঑‫̞̱ͥ̀׳‬ȃਗଽຸ͉Ȃྕ଻৖ۛͥ͢ͅ໅‫ك‬Ȃඅͅව͈֭͒‫͈ޣג‬೩ࡘͬ࿒എ̳͂ͥఉ̩͈ྕ଻৖ۛͼΣΏͺΞͻήͬା๵̱̞̀ͥȃ૤ະ஠͂ COPDȪྕ଻໾ण଻෹৖ۛȫ͈ۛ৪ͬచય̳͂ͥίυΈρθ̦ड͜ࢩ̩৘ঔ̯̞̦ͦ̀ͥȂ̭͈ͦͣίυΈρθ͉ͅȂۛ৪͈ప֭ࢃ͈έ΁υȜͺΛί࣐̠ͬ঑‫ࢌۭ׳‬঍͞ুহఘαȜΑ͈΍ȜΫΑ͈͂Ⴒࠈ̦̈́̓େࣺ̞ͤͦ̀ͥ͘ȃ! ! ྕ଻৖ۛΉͺͅࠈͩͥুহఘ͈֓ၷਲম৪͉ȂίρͼζςΉͺঔ୭͈ۭࢌ঍Ȃ೹ࠈ̳ͥ֓ၷ୺࿝‫ز‬Ȃୈ૰‫֓ش‬ၷਲম৪̜̈́̓́ͥȃ̭͈ͦͣ୺࿝‫͉ز‬Ȃਗ͈༗࠲൚ޫ̦नဥ
̱Ȃ‫ুڎ‬হఘ͈༗࠲ΓϋΗȜ͞ພ֭ͅ෻౾̯̞̹ͦ̀ͥ͛Ȃ๊֚૷ၷ͈ΑΗΛέ͂‫ފ‬ႁ̳̹͉ͥ͛ͅȂழ૕എ̜̞͉ͥ౷ၑഎ‫̹̜ͥͅྩު̢̀קͬٮޏ‬ຈါ̦̜ͥȃ! ! ྦྷ‫ۼ‬໐࿝͈֓ၷ༗ࡏ৪͉Ȃ୺࿝ު৪͈΍ȜΫΑͬ၌ဥ̱̀Ȃ༗ࡏ‫ح‬ව৪ਬ౬ͅచ̱̀
ুࡨ͈๯ဥ́ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̱̞̀ͥȃΟͻΐȜΒȆζΥΐιϋΠ̤̫ͥٚͅව঑‫༹͉༷׳‬Ȃഩდ̦৽̞͂̈́̽̀ͥȃ୶ܱ̱̹ͅ Medibank ͉Ȃခႁ̈́୺࿝ު৪̜́ͥ McKesson ͬฃਓ̱̹͈́Ȃুஜ́৘ঔ̳ͥ৘ঔࠁఠ̹͂̈́̽ȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟! ӱྕ଻৖ۛచॐͅ‫̳ͥ۾‬ଽॐ͈‫ڟ״‬! ! 2002 ා̥ͣႲཆଽຸȆਗଽຸ൝͈࠲ࢫ࿚ఴ౜൚ఱ૳́ࢹ଼̯̞ͦ̀ͥ‫̜ͥ́۾ܥ‬Australian Health Ministers' Advisory Council ͉Ȃྕ଻৖͈ۛထཡ͂Ήͺͅ‫࣭̳ͥ۾‬‫୽ز‬ၞͬ࠿൦̳̭̱ͥ͂͂̀Ȃ୺࿝‫ز‬տ֥ٛ͒ন࿚ͬࠐ̀Ȃ2003 ා 7 ࠮ͅ National-29-

Chronic Disease StrategyȪո‫ئ‬ȂNCDS ̞̠͂ȫ30ͬ৘ঔ̳̭ͥ͂ͬࠨ೰̱̹ȃ̭͈ N
CDS ͉Ȃൠෂພ͈̈́̓ 5 ͈̾ྕ଻৖ۛచॐ̜́ͥ National Service Improvement
Frameworks ͂ΓΛΠ̞̈́̽̀ͥͅȃ૽ș͈ুࡨ‫ۯ‬ၑȂྕ଻৖͈ۛࠑ௽എ́୨ͦ࿒̦̞̈́ΉͺȆထཡ̦̈́̓‫̞̯ͥ̀ͦ಺ޑ‬ȃ! ! 2011 ා̥ͣႲཆଽຸ͂ਗଽຸ൝͉ȂNational Health Reform Agreement ͬ೿̱ࠫȂΰσΑΉͺΏΑΞθ͈٨‫̞ͥ̀͛ૺͬڟ‬ȃ૽࢛͈ࣞႢ‫ا‬Ȃྕ଻৖ۛ๤ၚ͈ષઌȂ৖ພထཡ͈ຈါ଻̦Ȃ٨‫ͥ͛ૺͬڟ‬෸ࠊ̱̜̬̞͂̀ͣͦ̀ͥȃྕ଻৖ۛచॐͅ‫̳ͥ۾‬ଽॐ͜‫̤ͤ̀ͦ͘܄‬Ȃྕ଻৖͈ۛςΑ·ါ֦͂̈́ͥ๬ྖȂ୆‫ڰ‬ਠ‫͈̓̈́۝‬٨஝ͬ঑‫̳৾ͥ׳‬ழ࣐̠̱̞ͬ͂̀ͥȃ̹͘Ȃພ̥֭ͣίρͼζςΉͺ͈͒ਹ૤ͬ֊൲̳̭ͥ͂͜ྶ࡞̱ȂGP ͂ίρͼζςΉͺ٨‫̞̱ͥ̀͂ͥ͛ૺͬڟ‬ȃߓఘഎ͉ͅȂGP Super Clinics ȪGPȂۭࢌ঍Ȃvisiting medical specialists ̦̈́̓‫ފ‬൱̱̀ࡢ૽̹͉͘౷֖͒ΰσΑΉͺ΍ȜΫΑͬ೹‫̧̠ͥ́͢ͅރ‬঑‫̳ͥ׳‬ঔ୭ȫ͈ຽ‫ͬݞ‬଎ͥൎ঩࣐̠̭̱̞ͬ͂͂̀ͥȃ
Ӳ1990 ාయ̥͈ͣႲཆଽຸͥ͢ͅιΟͻΉͺੲ‫༷ۺ‬৆͈٨‫ڟ‬31!
ιΟͻΉͺ̤̞͉̀ͅȂGP ͈͒ੲ‫༷ۺ‬৆͉͂͂͜͜੄ြࣞ໡̞̜́ͤȂepisode αȜΑ͈঑໡ͅၻ̩ഐ؊̱̞̹̀ȃ̱̥̱Ȃ1990 ාయ̈́ͥ͂ͅȂιΟͻΉͺ̤̞̀ͅ episodeαȜΑ͈঑໡ͅၻ̩ഐ؊̱̞̹̀ GP ͈͒ੲ‫༷ۺ‬৆ͅ‫̢̀ح‬ȂႲཆଽຸ͉ࠑ௽എ̈́Ήͺͬఉ૖ਅ̦Ⴒࠈ̱̀೹‫̦̭̳͂ͥރ‬ຈါ̈́ྕ଻৖ۛͅచ؊̳ͥੲ‫༷ۺ‬৆͜൵ව̳ͥ٨
‫̧̹̀͛ૺͬڟ‬ȃ1991 ා͉ͅȂGeneral Practice Reform Strategy ͬ൵ව̱Ȃ1998
ා͉ͅ GP ͈૷ၷਫ਼̜́ͥ Practice ̞̾̀ͅ༫‫گ‬എ̈́ੲ‫༷ۺ‬৆͂̈́ͥȂIncentives
Program (PIP) ͬ൵ව̱̹ȃ1999-2000 ා͉ͅȂ Enhanced Primary Care (EPC) ͬ൵ව̱Ȃྕ଻৖ۛۛ৪ͅఉ૖ਅ‫͈಺ފ‬Ήͺ೹‫ͅރ‬చ̳ͥ༭ਫͬ஻୭̱̹ȃ2004 ා͉ͅGP ͂‫ފ‬൱̱యၑ̳ͥ practice nurse ͈͒༭ਫଷഽͬ஻୭̱Ȃ̷͈ࢃȂ2005 ා͉ͅ EPC
ͬ٨஝̱̹ȂChronic Disease Management (CDM) items ͬ൵ව̱̹ȃ̭͈̠͢ͅȂιΟͻΉͺ͈იඤ́Ȃੲ‫༷ۺ‬৆ͬ٨‫̳ͥڟ‬ଽॐ̦ജ‫̧̹̯̀ͦٳ‬ȃӳ‫ڎ‬ਗଽຸͥ͢ͅ߃ා͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθম႕! ਗଽຸ͉Ȃਗଽ़ຸ͈࡙͂Ⴒཆଽຸ͈༞੩߄ͬൎව̱̀ Community health servicesͬ৘ঔ̱̞̀ͥȃਗଽຸ͉ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐജ‫ͬٳ‬࣐̞̽̀ͥȃ̭̭͉́Ȃ2000 ා̥ͣ‫ڎ‬ਗ́৘ঔ̯̞ͦ̀ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬત̳ٚͥȃ̷͈࿒എ͉ྕ଻৖͈ۛව֭ဲଷͬ࿒ດ̱̞͈̦͂̀ͥ͜ఉ̞ȃ
New South Wales ਗ͉́Ȃྕ଻৖ۛۛ৪͈ව͈֭ཡগͅਹതͬ౾̞̹ NSW Chronic
Care Program ͬȂ2000 ා̥ͣ 2009 ා̥̫̀ͅ 3 ͈̾έͿȜΒͅ໦̫̀ജ‫̤̱̀ٳ‬ͤȂCOPD ͞૤ະ஠͈ۛ৪̤̫ͥͅව֭‫ઁࡘ͈ۼܢ‬൝͈࢘‫̦ض‬ං̹ͣͦȃྕ଻৖͈ۛ
National Health Priority Action Council (NHPAC), “National Chronic Disease Strategy”,
Australian Government Department of Health and Ageing, 2006.
31 The Australian Government Department of Health and Ageing, “Primary Health Care30

Reform in Australia: Report to Support Australia’s First National Primary Health Care
Strategy,” 2009, pp15-17.
-30-อછထཡͅਹതͬ౾̞̹ NSW Chronic Disease Prevention Strategy ͉Ȃ2003 ා̥ͣ2007 ා̤̞̀ͅജ‫̹̯ͦٳ‬ȃ૤௫ࠬ‫ࠏۯ‬৖ۛ͞ൠෂພ൝͈৖ۛͅ‫̢̀ح‬ιϋΗσΰσ
Α͜చય̱̤͂̀ͤȂ୆‫ڰ‬ਠ‫̰̯̫̤̈́ͥ͘͘ͅ۝‬ςΑ·ါ֦ͅಕ࿒̱̞̀ͥȃ̹͘Ȃထཡ͈̹͈͛৾ழ͈঑‫͞׳‬ͺδςΐΣ͈̠̈́ࣞ͢ςΑ·௄͈͒చ؊൝̦ਹത࣐൲ࣜ࿒
̱͂̀ࠇ̬̹ͣͦȃVictoria ਗ́৘ঔ̯̹ͦ Hospital Admission Risk program(HARP)͉Ȃྕ଻৖ۛۛ৪͈ව͈֭ဲଷͬ࿒എ̱͂̀ 2001 ාͅই൲̱Ȃ1 ͈ٝ޽‫ݢ‬ව̜̹͈֭ͤ໹޳ව֭‫̹̯ͦ෇ږ̦ض̳࢘ͥઁࡘ̦ۼܢ‬ȃIntegrated Chronic Disease
Management ȪICDMȫ͉Ȃྕ଻৖ۛۛ৪͈࠲ࢫેఠͬၻࢡͅ༗̹̾͛ͅȂ̯̰̈́֓͘͘ၷίυΨͼΘȜ̦Ⴒࠈ̱̀Ȃۛ৪͈ুࡨ‫ۯ‬ၑ͈঑‫࣐͞׳‬൲͈٨஝ͬ‫׳‬੩̳ͥ৾ழ
̜́ͥȃICDM ̤̫ͥۛͅ৪ুࡨ‫ۯ‬ၑ͈̹͈͛΍ȜΫΑ͈೹‫ރ‬Ȇ಺ାͬ৽̹ͥ࿒എ͂
̱̹ȂίρͼζςΉͺ͈ίυΨͼΘȜͥ͢ͅΩȜΠ΢ȜΏΛί͜ࢹಃ̯̞ͦ̀ͥȃਗၛίρͼζςΉͺ‫͈۾ܥ‬අ೰͈৾ழͬచયͅȂ༞੩߄̦࢐ັ̯̞ͦ̀ͥȃ2010 ාഽ͉ȂPDSA ΍ͼ·σͥ͢ͅ٨஝ȂΙȜθ֓ၷȂࠐफഎȆ২ٛഎͅະ၌̈́ਬ౬͈͒Ήͺ̦చય̞͂̈́̽̀ͥȃEarly Intervention in Chronic Disease in Community Health(EIiCD)͉Ȃ੿ြව͈֭ຈါ଻̦୆̴ͥ‫خ‬ෝ଻͈̜ͥྕ଻৖ۛۛ৪ͬచય̱̹͂Ȃ΋ηνΣΞͻαȜΑ்͈‫ܢ‬ٚව΍ȜΫΆ̜ͥȃWestern Australia ਗ̤̫ͥͅ Chronic
Disease Service ͉ȂൠෂພȂCOPDȂྕ଻૤ະ஠͈ۛ৪ͬచય̱̤͂̀ͤȂ࠲ࢫેఠ͈٨஝͂ুၛ̱̹୆‫͈ڰ‬௯ૺͬ࿒എ̱͂̀Ȃ̯̰̈́֓͘͘ၷΑΗΛέ̦ΙȜθͬழ଼̱ ̀ 3 ώ ࠮ ̥ ͣ 6 ώ ࠮ ͩͅ ̹ͤ ΍ ȜΫ Αͬ ೹ ‫ͥ ̜́ ͈ ͥ͜ ̳ރ‬ȃ Community
Physiotherapy ServicesȪCPSȫ͉Ȃၑ‫ڠ‬ၷ༹আͥ͢ͅ‫׋‬൲Ȇুࡨ‫ۯ‬ၑͬαȜΑ̱̹͂ٚවίυΈρθ̜́ͤȂྕ଻৖ۛۛ৪஠๊ͬచય̳͈͂ͥ͜Ȃඅ೰৖͈ۛۛ৪ͅέ΁Ȝ΃Α̱̹͈͜Ȃఘਹ໅‫ͅك‬ఛ̢̞ͣͦ̈́૽̫࢜ͅକಎ‫׋‬൲ͬαȜΑ̳͈͂ͥ͜൝Ȃਅș͈Ηͼί̦೹‫̞̯ͥ̀ͦރ‬ȃHospital in the Home ServicesȪHITHȫ͉Ȃུြව̦֭ຈါ̈́ۛ৪ͬව̵̴̯֭ͅȂౣ‫͈ۼܢ‬ह఺Ήͺ́చ؊̳ͥ৾ழ̜́ͥȃ24 শ‫͈ۼ‬ΨΛ·ͺΛίఘଷͬ৾ͤȂ֓ၷΑΗΛέͥ֓͢ͅഎ‫ۯ‬ၑ̦࣐ͩͦͥȃഩდͥ͢ͅ΋ȜΙϋΈ͜೹‫̦̞̯ͥ̀ͦރ‬Ȃۛ৪ͥ͢ͅুࡨ‫ۯ‬ၑ͈௯ૺ͈۷ത̥࣐ͣͩͦͥ೒ુ͈΋ȜΙϋΈ͈͕̥ͅȂව֭ಎ͈૤௫ພۛ৪͈̥̥̈́ͣ΋ȜΙ̦४‫ح‬৪ͬ஖೰̱࣐̀ͩͦ
ͥ The COACH Program ̦̜ͥȃThe COACH Program ͉Ȃྕ଻৖͈ۛ‫ۯ‬ၑ̤̫ͥͅহၷ͈ΆλΛίٜͬࠨ̳̹͈ͥ͛୽ၞ̱͂̀ȂMelbourne ఱ‫ ͈ڠ‬Margarite Vale ฎআ͈‫ٳ‬อͤ͢ͅȂ1995 ාͅΑΗȜΠ̱̹ȃThe COACH Program ͉Ȃ‫ેۍ‬൲ྤୈ૰৖
ۛȂෞ௾ಎȂ2 ߿ൠෂພ൝ͬచય৖̱̤ۛ͂̀ͤȂਗ͈࢖എ֓ၷ໐࿝Ȃྦྷ‫ۼ‬༗ࡏٛ২͂
̞̹̽၌ဥ৪௰̦ΠτȜΣϋΈͬ਋̫̀Ȃۛ৪͈͒΋ȜΙϋΈ͈࿨‫ͬڬ‬౜̠̭͂͂̈́
̞̽̀ͥȃ̹͘ȂWeb αȜΑ͈ΕέΠ;Ϳͺ̤̞̀ͅȂ΋ȜΙϋΈͅ‫̰̯̳ͥ͘͘۾‬̈́‫ܥ‬ෝ̦೹‫̞̯ͥ̀ͦރ‬ȃ㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ⃻⁁ߣ᡽╷⺖㗴؎ਗͬಎ૤ͅ 8 ώ࣭͈ΟͻΐȜΒȆζΥΐιϋΠͬ๤‫ڛ‬໦ଢ଼̱̹Ȃ ා࢖ນ͈༭࣬

-31-੥32͉Ą͈̤̑̾͂ͤঐഊ̱̞̀ͥȃ! ! NCDS ͅ‫̱̀۾‬Ȃۛ৪൝͈ুࡨ‫ۯ‬ၑ͂΋ηνΣΞͻΉͺ̤̫ͥͅΉͺͬਹণ̳ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͂ାࣣഎ̜́ͤȂΟͻΐȜΒȆζΥΐιϋΠͅ‫̱۾‬ಿ‫ܢ‬എণത̥ͣ঩߄ͬ‫ږ‬༗̱̞̀ͥത͉ບ‫̧ͥ́ث‬ȃ̱̥̱Ȃ‫ ͈ܢ଻ݢ‬episode αȜΑ͈੄ြࣞ໡̞͈ MBS ͉́Ȃྕ଻৖ۛͅ‫̳ͥ۾‬ΟͻΐȜΒȆζΥΐιϋΠ͈ജ‫͉ͅٳ‬ഐࣣഎ͉̞́̈́ȃࣽࢃ͈ଽॐ‫ه‬ఴ̱͂̀Ȃచય৪͈ুࡨ‫ۯ‬ၑෝႁͬࣞ͛ͥ঑‫׳‬ॐ͈٨஝Ȫ΋ȜσΓϋΗȜ͈̈́̓‫ڐ‬ਰȫȂ༗࠲૖Ȇ֓ၷ༗࠲‫͈۾ܥ‬Ⴒࠈ‫اޑ‬ȂGP ̷͈͂ఈ͈֓ၷ༗࠲‫۾ܥ‬͈Ⴒࠈ‫اޑ‬Ȃͤ࢘͢‫࢖̦̜̦ͥض‬എ໐࿝͂জഎ໐࿝़͈࡙͈‫ވ‬ခȆ೹ࠈ͈‫اޑ‬Ȃૂ༭೒૞ܿ੅͈֚௄͈‫ڰ‬ဥ̜̬̞ͬ̀ͥȃ! ! ̹͘ȂLa Trobe University ͈ Australian Institute for Primary Care ̦ 2008 ාͅ࢖ນ̱̹༭࣬੥͉́Ȃ࡛࣐͈ιΟͻΉͺ̤̞̀ͅ৘ঔ̱̞̀ͥίυΈρθͅൎ̲̞ͣͦ̀
ͥထॳ͂ȂHACC program ͈̈́̓ਗଽຸ̦৘ঔ̱̞̀ͥ community health ͈ίυΈρθ͈ထॳͬൡࣣ̳̭ͥ͂ͬ೹մ̱̞̀ͥ33ȃ

Nolte E et al, “Managing chronic conditions: Experience in eight countries”, European
Observatory on Health Systems and Policies, 2008.
33 Swerissen H and Taylor M, “System reform and development for chronic disease
management. A report prepared by the Australian Institute for Primary Care”, La Trobe
University, 2008.
32

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╙  ▵ ࠪࡦࠟࡐ࡯࡞34
㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊ӱ࣭͈අಭȆ‫ڟ״‬! Ώϋ΄εȜσ͉Ȃ࿂ୟ 707 ໹༷΅υιȜΠσȂ૽࢛ 508 ྔ૽Ȫ̠̻ȂΏϋ΄εȜσ࣭ୠȆ‫ז‬ਯ৪͉ 377 ྔ૽ȃ2010 ාȫ͈സঌ࣭‫̜ͥ́ز‬ȃྦྷ௼͉Ȃಎ‫ ࠏل‬75ɓȂζτȜࠏ 14ɓȂͼϋΡࠏ 9ɓ̈́̓́ࢹ଼̯ͦͥȃ! 1959 ාͅ‫ু̥࣭ͣם‬হࡀͬ‫ڕ‬ං̱ȂΏϋ΄εȜσুহਗ͂̈́ͤȂ1963 ාζτȜΏͺ଼ၛশ͉ͅȂζτȜΏͺ͈ 1 ਗ̦͂̈́ͥȂ1965 ා͉ͅζτȜΏͺͤ͢໦ၗȂΏϋ΄εȜσ‫ވ‬გ࣭͂̈́ͥȃ൐ධͺΐͺ்͈̥̞̈́́͜শ‫ࠐ̞̥ࣞͣܢ‬फ଼ಿͬଛ̬Ȃ඾ུͬ‫͚܄‬ͺΐͺ੨࣭͈̥̈́́͜ड͜ཅ̥࣭͈̈́ 1 ̜̾́ͥȃӲΰσΑΉͺΏΑΞθȪ೹‫ރ‬ఘଷ़࡙͂಺ో༷৆ȫ͈අಭȪ˝ȫ֓ၷ೹‫ރ‬ఘଷ! Ώϋ΄εȜσ͈֓ၷ೹‫ރ‬ఘଷ͉Ȃ֚ষ֓ၷȪίρͼζςΉͺȫͬ౜̠૷ၷਫ਼͂Ȃඵষ֓ၷ࣐̠ͬພ֭ͅఱ༆̯ͦͥȃ૷ၷਫ਼͈̠̻Ȃ20ɓ̦ες·ςΣΛ·͂ࡤ͊ͦͥ࢖എΓ·ΗȜ͈૷ၷਫ਼̜́ͤȂॼ͈ͤ 80ɓ͉Ȃ‫૷ͥ֓͢ͅުٳ‬ၷਫ਼̞͂̈́̽̀ͥȃພ͉֭Ȃພ઄ତ́ࡉͥ͂࢖എΓ·ΗȜͅ௺̳͈̦ͥ͜ 80ɓȂྦྷ‫ۼ‬ພ̦֭ 20ɓ̤͂̈́̽̀ͤȂ࢖എΓ·ΗȜ̦৽ఘ̞͂̈́̽̀ͥȃ࢖എΓ·ΗȜ͉Ȃඵ͈̾֓ၷίυΨͼΘȜȪNational Healthcare GroupȂ
Singapore Health Serviceȫͅ໦̫̤ͣͦ̀ͤȂΏϋ΄εȜσͬ൐ୌͅඵ໦̱̀౜൚̱̞̀
ͥȃ̷̸͈ͦͦ֓ၷίυΨͼΘȜͅȂ௙ࣣພ֭Ȃ୺࿝ພ֭Ȃες·ςΣΛ·̦௺̱̞̀ͥȃ! ྕ଻৖͈ۛ‫ٸ‬ြহၷ͉Ȃ૷ၷਫ਼̦౜̞̽̀ͥȃ࢖എΓ·ΗȜ͈ες·ςΣΛ·͉́ 1 ঔ
୭ͅ 12 ྴ̥ͣ 20 ྴ೾ഽ͈֓঍Ȃ࿩ 20 ྴ͈ۭࢌ঍Ȃ̷͈ఈႉ઄૤ၑআȂၑ‫ڠ‬ၷ༹আȂ‫ူו‬আȂ΃;ϋΓρȜ̞̹͂̽୺࿝૖̦෻౾̯̞ͦ̀ͥȃȪ˞ȫ़࡙಺ో༷৆! Ώϋ΄εȜσ͉́Ȃ֓ၷͅ‫༷ో಺़࡙̳ͥ۾‬৆͉Ȃࡢ૽͈ু੩ͬஜ೹̱͂̀ࢹಃ̯̞ͦ̀ ͥ ȃ ஠ ࣭ ྦྷ ͂ ‫ ז‬ਯ ࡀ ৪ ͅ ‫ ح‬ව ̦ ݅ ྩ ັ ̫ ͣ ͦ ̀ ̞ ͥ ‫ ޑ‬ଷ ಡ ಇ ࢛ ज CPF Ȫ Central
Provident Fundȫ̦֓ၷ़࡙಺ోͅ‫৽̱̀۾‬ါ̈́‫ܥ‬ෝͬ౜̞̽̀ͥȃCPF ͉Ȃਯ఺ࣔව঩
߄Ȃ‫֗ޗ‬঑੄Ȃప૖ා߄̈́̓ဥഷ̮͂ͅໝତ͈࢛जͅ໦̥̞̦ͦ̀ͥȂ࢛ज͈ 1 ̱̾͂̀֓ၷ๯ͅ၌ဥ̳ͥιΟͻΓͼήȪMedisaveȫ̦୭̫̞ͣͦ̀ͥȃCPF ͅȂιΟͻΓͼή̦൵ව̯̹͈͉ͦ 1984 ා̜́ͥȃιΟͻΓͼῄ͉Ȃ੿ြ͈֓ၷ๯঑੄ͅ๵̢̀Ȃਓව͈֚೰‫ࣣڬ‬Ȫ๭ဥ৪͈ાࣣ͉ͅমު৽͂๭ဥ৪͂୬฼́‫੄ݶ‬ȫ̦ୟ͙ၛ̀ͣͦͥȃιΟͻΓͼ
ή͈ୟ͙ၛ̦̀၌ဥ̧͈͉́ͥව֭ͤ͢ͅอ୆̳ͥව֭๯ဥȂ֓঍๯ဥȂ࿪स๯ဥ̜́ͤȂུ୯͉Ȃ2008 ා 12 ࠮ 29 ඾ͅ‫ٳ‬ट̯̹ͦల 8 ٝΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬̤̫ٛͥͅ Cheah Jason ঙȪNational Healthcare Group Singapore Chief Projects Officerȫ࣒ͥ͢ͅ‫׵‬ඤယͬࡓͅমྩޫ̀ͅठࢹ଼̱̀ै଼̱̞̀ͥȃ̱̹̦̽̀Ȃུ୯ܱͅश̯̞ͦ̀ͥඤ
ယ̞͉̾̀ͅȂ࣒‫׵‬൚শ͈͈̜́ͥ͜ȃCheah Jason ঙ͈࣒‫׵‬ါক͉ȂDM ଽॐ‫ه‬ఴࡄ‫ݪ‬͈ٛHP< http://www.sj-ri.co.jp/research/healthcare_socials/proceedings_pc/08.html>ͅࠇश̯ͦ
̞̀ͥȃ

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ࡔ௱̱͂̀‫ٸ‬ြ૷ၷ͉చય̯̭̥̹͂ͦ̀̈́̽ȃ̱̥̱Ȃ࡛ह͉́Ȃࢃ੆̳̠֚ͥ͢ͅ໐
͈ྕ଻৖͈ۛ‫ٸ‬ြহၷ͜ͅιΟͻΓͼή̦ഐဥ̯̠̞ͦͥ̈́̽̀ͥ͢ͅȃ̹͘ȂιΟͻΓͼῄ͉Ȃව֭ 1 ඾൚̹ͤȂ਀੅๯͉਀੅͈ඤယͥ̈́̓͢ͅ‫͈ັݯ‬ષࡠ̦೰̞͛ͣͦ̀ͥȃ! ιΟͻΓͼήͬ༞௷̳ͥ࿒എ́୭̫̞͈̦ͣͦ̀ͥȂιΟͻΏȜσΡȪMediShieldȫ̜́ͥȃιΟͻΏȜσΡ͈͒‫ح‬ව͉Ȃ΂ίΠͺ;Π༷৆Ȫ‫ح‬ව‫ݵ‬๛͈փএນা̱̞ͬ̈́ࡠͤ
ু൲‫ح‬වȫ̞͂̈́̽̀ͥȃιΟͻΏȜσΡ͉Ȃ༗ࡏ͈ࠁఠ̤ͬ৾̽̀ͤȂ༗ࡏၳ͉Ȃ༗વ߄‫ڣ‬Ȃ‫ح‬ව৪͈ාႢͤ͢ͅࠨ೰̯ͦͥȃιΟͻΏȜσΡ͉ȂιΟͻΓͼή͈‫ັݯ‬ષࡠͬષ̹ٝ̽֓ၷ๯঑੄ͅਰ̧̭̦͕̥̀ͥ͂́ͥȂඅ೰͈‫ٸ‬ြহၷ๯͜ͅਰ̧̭̦̀ͥ͂́ͥȃιΟͻΏȜσΡ͉ͅȂා‫͍̤֚͢ۼ‬୆‫ັݯ̸̷͈ͦͦپ‬ષࡠ̦୭̫̞ͣͦ̀ͥȃ! ̭͈͕̥ȂιΟͻΏȜσΡͤ͢͜‫ັݯ‬ષࡠ̦̩ࣞഐဥํս̦ࢩ̞හփ‫ح‬ව͈༗ࡏଷഽ̦
୭̫̞̹̦ͣͦ̀Ȃ2005 ා̥͉ͣȂMedisave-approved Integrated Shield Plan ̱͂̀ȂιΟͻΏȜσΡ͈͂஖఼৆́‫ح‬ව̳̠̞ͥ̈́̽̀ͥ͢ͅȃӲΏϋ΄εȜσ̤̫ͥͅྕ଻৖͈ۛે‫ޙ‬! Ώϋ΄εȜσ͈ࣞႢ‫ا‬ၚ͉࿩ 9ɓ͂Ȃ඾ུȂ؎ༀ୶ૺ࣭͂๤͓ͥ͂ջட೩̞କ੔̜̦ͥͅȂ੄୆ၚ̦೩̞̭̜͂ͤ͜Ȃࣽࢃ‫ࣞͅ௸ݢ‬Ⴂ‫̳࣐͂ͥૺ̦ا‬ထே̯̞ͦ̀ͥȃΏϋ΄εȜσ͉́Ȃ6 ාͅ 1 ٝȂNational Health Survey ̦৘ঔ̯ͦȂ̷͈۪̱֚͂̀ྕ଻৖͈ۛခພ
ၚȂςΑ·ါ֦ͅ‫಺̳ͥ۾‬औ̦࣐̞ͩͦ̀ͥȃ2004 ා͈಺औͅ‫̩͂̿ܖ‬Ȃ18 प̥ͣ 69 प଼͈́͘૽͈̠̻Ȃൠෂພ͈ခພၚ 8.2%Ȃࣞࠬգછ 20.1%Ȃࣞডࠬછ 18.7%͈͂ࠫ‫̈́͂ض‬̞̽̀ͥȃࣽࢃ͈ࣞႢ‫ฺ̞ͅا‬Ȃྕ଻৖ۛచॐ͈ਹါ଻̦ࣞͥ͂͘෇ে̯̞ͦ̀ͥȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟! Ώϋ΄εȜσ͉́ۜஅછ̦৽ఘ̜̹́̽৖ພࢹ௮̦་‫̱ا‬Ȃྕ଻৖͈ۛခພၚ̦ࣞ̽͘
̧̹̭̀͂ͬ਋̫̀Ȃਲြ͈ພ֭ͬ৽ఘ̳͂ͥ֓ၷ೹‫ރ‬ఘଷ͈་‫̦ڟ‬ຈါ̜͈́ͥ͂෇ে
̧̦̹ࣞ̽̀͘ȃΏϋ΄εȜσଽຸ͉ȂίρͼζςΉͺ̦ྕ଻৖ۛͬ‫ۯ‬ၑ̳ͥਹါ̈́ΏΑΞθ̜͈́ͥ͂෇ে͈͂͜Ȃۛ৪̦ഐ୨̈́ાਫ਼Ȃশ‫ܢ‬Ȃ๯ဥ́‫ږ‬৘̈́Ήͺͬ਋̫̭̦ͥ͂
̧̭́ͥ͂ͬ࿒ດ̱͂̀Ȃες·ςΣΛ·Ȃ౷֖ພ֭ȂࣞႢ৪໛ছঔ୭͈ൎ঩ͅਹത̤ͬ
̩̠͢ͅଽॐഢ۟ͬ଎̧̞̽̀̀ͥȃྕ଻৖ۛచॐ̱͈͂̀ΟͻΐȜΒȆζΥΐιϋΠ͉ȂίρͼζςΉͺͬ౜̠֓঍̦ಎ૤എ̈́࿨‫ͬڬ‬౜̠͈̱͂̀͜ࢹ଼̯̞ͦ̀ͥȃ! ൳শͅȂ़࡙಺ో͈࿂́͜ྕ଻৖ۛহၷͬਹণ̳༷ͥ࢜ͅഢ۟ͬ଎ͤȂ2006 ා̥ͣȂൠෂພȂࣞࠬգછȂࣞডࠬછ͈̈́̓ྕ଻৖͈ۛ‫ٸ‬ြহၷͅιΟͻΓͼή̦ഐဥ̧̠́ͥ͢ͅ
ଷഽ٨೰̦৘ঔ̯̞ͦ̀ͥȃ̷͈ࢃȂቋ௳Ȃྕ଻໾ण଻෹৖͈ۛ‫ٸ‬ြহၷ͜ιΟͻΓͼή
͈ഐဥ̦਋̫̠̞ͣͦͥ̈́̽̀ͥ͢ͅȃ㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ⃻⁁ߣ᡽╷⺖㗴ӱΟͻΐȜΒȆζΥΐιϋΠ͈‫ུܖ‬എࣉ̢༷! Ώϋ΄εȜσଽຸ͉Ȃྕ଻৖ۛచॐ̱͈͂̀ΟͻΐȜΒȆζΥΐιϋΠͬྕ଻৖͈ۛۛ

-34-

৪̦౜൚̳ͥ֓঍͂͂͜ͅ೰‫ܢ‬എ̈́κΣΗςϋΈȂഐ୨̈́֓ၷੜ౾ȂρͼέΑΗͼσ͈٨஝Ȃুͣୟޭഎͅ৖ۛͬ‫ۯ‬ၑ̳̭ͥ͂Ȃྕ଻৖͈ۛۛ৪ͬ౜൚̳ͥ֓঍ͥ͢ͅఘࠏഎ̥̾
΀ΫΟϋᾼ‫̩̿ܖ‬ΟͻΐȜΒȆζΥΐιϋΠ͈ίυΠ΋σ͈ਖ਼৿ͬ଎̭ͥ͂Ȃ͂೰̱̞݅̀ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬࢹಃ̳ͥष͈‫ུܖ‬എ̈́κΟσ̞͈͉̈́̽̀ͥͅχΈ΢ȜκΟσ̜́ͥȃχΈ΢ȜκΟσ̱̹̦̞ͅȂౙ̈́ͥΰσΑΉͺΏΑΞθ̱͉͂̀́
̩̈́ȂΰσΑΉͺΏΑΞθͬ঑̢ͥ΋ηνΣΞͻΏΑΞθ̜͈́ͥ͂ࣉ̢༷́ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ࢹಃ̯̞ͦ̀ͥȃ̷̱̀ஜ੆͈̤͂ͤȂίρͼζςΉͺͬ౜̠֓঍̦ಎ૤̦͂̈́ͥȂ୺࿝͉̲̳֓ͬ͛͂ͥఉအ̈́୺࿝૖͂Ⴒࠈ̱̀ۛ৪͈৖ۛͬ‫ۯ‬ၑ̳ͥκΟσ͈ࢹಃ̦࿒ঐ̯̞ͦ̀ͥȃ! ̹͘ȂITȪૂ༭೒૞ܿ੅ȫ͈‫ڰ‬ဥ̦ΟͻΐȜΒζΥΐιϋΠ͈৘ঔͅਹါ͈͂෇ে͈͜
͂Ȃ2004 ා͉ͅଽຸ̦ Electronic Medical Record ExchangeȪRMRXȫ͂ࡤ͐ॽழ͙ͬࢹ
ಃ̱Ȃۛ৪͈పܱ֭჏Ȃ࠿औࠫ‫͈ض‬ພ֭‫ވ͈́ۼ‬ခ‫ͬا‬৘࡛̱̹͕̥Ȃ֓ၷܱ჏͈ഩঊ‫ا‬ͬଔૺ̱̞̀ͥȃӲΟͻΐȜΒȆζΥΐιϋΠ͈৘႕! Ώϋ΄εȜσ͉́Ȃໝତ͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦Ȃଽຸ͈ίυΈρθ
̱͂̀ଽຸ༞੩ͬ਋̫̀৘ঔ̯̞ͦ̀ͥȃ̭̭͉́ȂNational Healthcare GroupȪո‫ئ‬ȂȶNHGȷȫ̦৘ঔ̱̞̀ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̞̾̀ͅત̳ٚͥȃ࡛हȂ
NHG ͉́Ȃ‫଻ࠬݹ‬૤৖ۛȂ૤ະ஠Ȃቋ௳Ȃྕ଻໾ण଻෹৖ۛȂ෹‫׶‬ȂෞࢸणȂൠෂພȂࣞࠬգȂࣞডࠬછȂဲ̠̾Ȃࣸல̱̠͡છ̞̹͂̽ఉ‫̹ͥͩͅܚ‬ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ‫ٳ‬อ̱ۛ৪ͅ೹‫̞̱ͥ̀ރ‬ȃNGH ͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ
͈ࡔ௱̱͂̀ո‫ ͈ئ‬5 ̾ͬਹণ̱̞̀ͥȃȪ˽ȫ։̈́ͥાਫ਼́͜൳̧༹̲̠༷̈́́́ͥ͢ॽழ͙̤͍͢ίυΓΑȪ˾ȫ΀ΫΟϋᾼ‫ͼ΄̹̞̿ܖ‬Ρρͼϋ̤͍͢ੜ౾
Ȫ˿ȫۛ৪͈͒΀ϋΩχȜιϋΠ̤͍͢ྕ଻৖͈ۛΓσέζΥΐιϋΠ
Ȫ̀ȫພ֭၌ဥ͈ࡘઁ̤͍͢डഐ̈́Ήͺτασ͈͒֊࣐Ȫ́ȫྕ଻৖͈ۛ‫ۯ‬ၑΏΑΞθ̜̭́ͥ͂
! ड੝ͅ NHG ̦‫ٳ‬อ̱̹ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ቋ௳ۛ৪ͬచય̱̹͜ͅ
͈̜́ͥȃਲြȂ൳̲ቋ௳ۛ৪̦ພ͈֭͒වప֭ͬ߫ͤ༐̳̞̠͂মఠ̦ఉ̩ࡉ̹ͣͦȃ̭͈ၑဇ͈ 1 ͉̾Ȃۛ৪ͅቋ௳͈อैͬཡ̪̹͈͛୆‫ڰ‬ਠ‫̳ͥ۾ͅ۝‬౶ে̦ະ௷̱̞̹̀
̭͂Ȃ̠͜ 1 ͈̾ၑဇ̦ൎ࿪ͅ࿚ఴ̦̜̹̭̜̹̽͂́̽ȃ̷͈̹͛ȂNHG ͉́Ȃቋ௳ۛ৪͈Ήͺ͂୆‫͈ڰ‬ৗ͈٨஝ͬ๯ဥ࿂́ड࢘͜‫༹༷̞͈́ࣞض‬৘࡛̳̹͈ͥ͛ࢹ௮‫̹̯ͦا‬ൡࣣഎ́ఉ࿂എ̈́ίυΈρθ͈ࢹಃͬ࿒ঐ̳̭̱̹͂ͅȃ̭̠̱̀Ȃቋ௳ۛ৪ͅచ̳ͥ·ςΣ΃σȆΩΑͬै଼̱ȂίρͼζςΉͺ࣐̠ͬ૷ၷਫ਼Ȃພ͈֭́‫ވ‬ခ‫ا‬Ȃۛ৪‫֗ޗ‬ίυ

-35-Έρθ͈‫ٳ‬อȂࡢ༆‫̹̯ͦا‬হၷْ͈ࠗॐ೰̞̹͂̽ါள̥ͣࢹ଼̯ͦͥίυΈρθ̦‫ٳ‬อ̯̹ͦȃ̭͈ίυΈρθ͈৘ঔͤ͢ͅȂ‫͈଻ݢ‬ቋ௳อैȂࡤ‫ࣾݟ‬ඳͥ͢ͅພ֭၌ဥ৪ତ
͉ාșࡘઁ̧̱̞̀̀ͥȃNHG ̷͈͈ࢃ͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈‫ٳ‬อ͉Ȃ̭͈ቋ௳ۛ৪̫࢜ίυΈρθ͈‫ٳ‬อ͈ࠐࡑͬ൩̢̀͘৘ঔ̯̞ͦ̀ͥȃӳΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫ه̳ͥ۾‬ఴ
Cheah Jason ঙ͉ȂΏϋ΄εȜσ̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈‫ه‬ఴ̱͂̀ষ͈ത̜̬̞ͬ̀ͥȃȆ‫͈͂֓ުٳ‬Ⴒࠈ̦਱໦ͅ଎̞̞̭ͣͦ̀̈́͂ȃ‫͉֓ުٳ‬Ȃু໦͈ۛ৪ͬ਀༶̱̹̩̞̈́
̹͛Ȃఈ͈୺࿝͈֓͒તٚͬ๰̫̞̹࣐ͥ͂̽൲̭̦֦̞֚ͬ৾ͥ͂͂̈́̽̀ͥȃȆιΟͻΓͼή͈ഐဥͬ਋̫̱ͣͦͥ͂̀͜৘ৗ͉ু๯૷ၷ̜̹́ͥ͛Ȃۛ৪ͅచ̳ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ४‫ͼ̳ͥح‬ϋΓϋΞͻή୭̦ࠗඳ̱̞̭͂ȃ̹̺̱Ȃ࡛ह͉́ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ఉ̩̦ଽຸ͈ίυΈρθ̱͂̀༞੩ͬ਋
̫̤̀ͤȂۛ৪໅౜̦୆̲̞̞̹̀̈́͛Ȃఱ̧̈́‫ه‬ఴ͉̞̞͂̈́̽̀̈́ȃȆ੿ြഎ̈́‫ه‬ఴ̱͂̀ȂࣞႢ‫ૺ̦ا‬ജฺ̳͈̞ͥ֓ͅၷ͂ΕȜΏλσΉͺ͈ൡࣣ̦ຈါͅ
̈́ͥ͂ࣉ̢̭ͣͦͥ͂ȃCheah ঙ͉Ȃ֓ၷ͂ΕȜΏλσΉͺ͈஼༷ͬ൳̲ίυΨͼΘȜ̦೹‫̳ͥރ‬౷֖͈ζσΙ΍ȜΫΑΓϋΗȜ͈஻୭̦ίυΐͿ·Π̱͂̀ૺ̞͛ͣͦ̀ͥ͂დ
̱̞̀ͥȃ̹͘Ȃ౷֖̤̫ͥ֓ͅၷ͂ΕȜΏλσΉͺ஼༷͈Ήͺ΋ȜΟͻΥͼΠ࣐̠ͬ΋ηνΣΞͻΉͺۭࢌ঍଼͈̦֗ૺ̞̱̞͛ͣͦ̀ͥ͂̀ͥȃ-36-╙  ▵ ⧷࿖㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊! ӱ࣭͈අಭȆ‫ڟ״‬‫࢖͈࣭ם‬৆ນܱ͉ȂΈτȜΠȆήςΞϋ̤͍͢ཤͺͼσρϋΡႲࣣ࣭ؐȪUnited
Kingdom of Great Britain and Northern Irelandȫ̜́ͥȃႲࣣ࣭ؐȪUnited Kingdomȫ
͉ͼϋΈρϋΡȂΑ΋ΛΠρϋΡȂ;ͿȜσΒ̤͍͢ཤͺͼσρϋΡ̥ͣࢹ଼̯̞ͦ̀
ͥȃུ୯͉́ȂႲࣣ࣭ؐ஠ఘͬঐ̳ાࣣͅ‫࣭͂ם‬ນܱ̱Ȃ̷ͦո‫ͼ͉ٸ‬ϋΈρϋΡȂΑ΋ΛΠρϋΡ͈̈́̓ນܱͬဥ̞ͥȃ‫͈࣭ם‬࿂ୟ 242,514 ໹༷΅υιȜΠσ(඾ུ͈࿩ 65ɓ)૽࢛ 6,179 ྔ૽(2009 ාȂଔࠗ౵Ȃ੄ਫ਼ȇ‫ྦྷ࣭࣭ם‬ൡࠗޫȪONSȫȫ̜́ͥ35ȃ
‫͉࣭́ם‬Ȃ݈֥ඤ‫ڝ‬ଷ̤ͬ৾̽̀ͤȂ৽ါଽൂ͉༗৿ൂȂႻ൱ൂȂুဇྦྷ৽ൂ̜́ͥȃ
1979 ාͅ΍ΛΙλȜ̦ၚ̞ͥ༗৿ൂ̦ଽࡀൂ̈́ͤͅȂ1997 ා͉ͅήτͺ̦ၚ̞ͥႻ൱ൂ
̦ଽࡀൂ̹̈́̽ͅȃ̷͈ࢃȂ2010 ා͉ͅ༗৿ൂ͂ুဇྦྷ৽ൂ͈Ⴒၛଽࡀ଼̦ၛ̱̹ȃӲΰσΑΉͺΏΑΞθȪ೹‫ރ‬ఘଷ़࡙͂಺ో༹༷ȫ͈අಭ͂ଽॐ͈་஗
‫͈࣭ם‬ΰσΑΉͺΏΑΞθ͉ͅȂྦྷ‫ۼ‬༗ࡏ͂၌ဥ৪͈জ๯໅౜̽̀͢ͅȂྦྷ‫ۼ‬໐࿝͈ΰσΑΉͺ΍ȜΫΑͬ၌ဥ̳ͥॽழ͙͂Ȃ़࡙͈͕͂ͭ̓ͬଽ़ຸ͈ଽ൝̥ͣං̀ȂထཡȆςΧΫςΞȜΏοϋͬ‫͚܄‬ΰσΑΉͺ΍ȜΫΑͬȂ஠ਯྦྷͅ೹‫ ̳ͥރ‬National
Health Service (ո‫ئ‬ȂNHS ̞̠͂) ͈ॽழ͙͈ၰ༷̦ంह̱̞̀ͥȃNHS ͉ȂΰσΑΉͺ΍ȜΫΑͬ஠ਯྦྷͅచ̱̀೹‫̳֓ͥރ‬ၷ༗વଷഽ̱͂̀ခ࢘ͅ‫ܥ‬ෝ̧̱̹༷֚̀Ȃ‫͈࣭ם‬ಎ؇ଽຸ̦೰͛ͥထॳ͈ํսඤْ́ࠗഎͅ೹‫̹̯͛ͥͦރ‬Ȃ‫ݯރ‬ະ௷͈ાࣣ͉ͅ
ఉ̩͈ఞ‫ܥ‬৪ͬ୆͙੄̳͈̈́̓࿚ఴത͜༴̢̧̹̀ȃ! ! ࿚ఴത͈ٜࠨ͈̹͛ͅȂ̷̸͈ͦͦଽࡀ͉ȂNHS ͅ‫̳ͥ۾‬ଽॐ໲੥ͬฒ੥̱͂̀࢖ນ
̱Ȃ٨‫̧̹̀͛ૺͬڟ‬ȃ႕̢͊Ȃ΍ΛΙλȜଽࡀ͉́ internal market ͬ൵ව̱̹͈̦Ȃ̷͈֚႕̜́ͥȃΰσΑΉͺͅ‫̳ͥ۾‬ଽॐȂඅͅ NHS ͅ‫̳ͥ۾‬ଽॐ͉ુͅఱ̧̈́஖‫͈ݷ‬௔ത̧̹̈́̽̀ͅȃଽࡀ࢐య͉ȂNHS ̈́̓ͅ‫̳ͥ۾‬ଽॐ͈༷࢜଻ͬऒֲ̳ͥȂఱ̧̈́੄ြম̜́ͥȃ‫͈࣭ם‬ଽࡀ࢐య͉Ȃ‫࣭ם‬஠ఘ͈ΰσΑΉͺ͈ଽॐͅఱ̧̩‫ͬޣג‬ဓ̢̦ͥȂఈ༷ͼϋΈρϋΡȂΑ΋ΛΠρϋΡȂ;ͿȜσΒȂཤͺͼσρϋΡ̷̸͉ͦͦඊু̈́౷
༷ুহଷഽͬခ̱ȂͼϋΈρϋΡȂΑ΋ΛΠρϋΡȂ;ͿȜσΒȂཤͺͼσρϋΡ̷̸͉ͦͦඊু଻̦̜ͥΰσΑΉͺ΍ȜΫΑଽॐͬജ‫̞̱ͥ̀ٳ‬ȃNHS ͜Ȃ൳͈֚ࡔ௱ͅ௱
ͤ‫ͼ̦̞̯ͥ̀ͦא׋‬ϋΈρϋΡȂΑ΋ΛΠρϋΡȂ;ͿȜσΒȂཤͺͼσρϋΡ֑̞̦̜́ͤȂOne system- four structures ͂ઠ̯̞ͦ̀ͥ36ȃ
NHS ͉Ȃࢹ௮എ֚ͅষ֓ၷ͂Ȃඵষ֓ၷ͈ྶ‫ߊ̈́ږ‬໦̦̜ͥȃ̳̻̈́ͩȂ๊֚֓ȪGeneral Practitioner. ո‫ئ‬Ȃུ୯͉́ GP ̞̠͂ȫͬ৽̈́౜̞਀̳͂ͥίρͼζςΉͺ(֚ষ֓ၷ)͂Ȃພ֭͂୺࿝֓ͬ৽̹ͥ౜̞਀̳͂ͥΓ΃ϋΘςȜȆΉͺ(ඵষ֓ၷȃ35඾ུཟօ૦‫ࢹܥޟ‬ȪΐͿΠυȫ͈࣭Ȇ౷֖༆ૂ༭ͥ͢ͅȃ
The NHS Confederation, “The NHS handbook 2010/11”, 12th ed. The NHS Confederation,
2010.
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secondary care )̦৽̹ͥࢹ଼ါள̧̞͂̈́̽̀̀ͥȃ̱̥̱ȂNHS ͉Ȃ̭͈ఈ͜ͅ΍ȜΫΑ೹‫̞࣐ͥ̀̽ͬރ‬ȃ႕̢͊ȂͼϋΈρϋΡ͈ NHS ͉́Ȃ޽‫֓ݢ‬ၷȂCommunity healthservices Ȃ Integrated care ̈́ ̓ ͈ ΍ Ȝ Ϋ Α ͬ ೹ ‫ ͂ ͥ ̞ ̀ ̱ ރ‬୰ ྶ ̯ ͦ ̀ ̞ ͥ 37 ȃCommunity health services ͉͂Ȃ΋ηνΣΞͻ஠ఘ͈ਯྦྷͬచય̳͂ͥထཡ୪ਅȂ৖ພထཡ͈΍ȜΫΑ͂Ȃ৖ພȆવ‫ͬٺ‬ခ̳ͥۛ৪ͅచ̱̀ȂΓράΑΠ̜́ͥ Allied healthprofessional ͞ Community nurse ̈́̓̽̀͢ͅȂພ֭‫́ٸ‬೹‫̯ͥͦރ‬ੜ౾ȆΉͺ͈΍ȜΫΑ̞̠ͬȃIntegrated care ͉͂ȂGPȂCommunity nursesȂ࿪स঍ȂSocial care teamsȂ
޽‫֓ݢ‬ၷ΍ȜΫΑ͈̈́̓ఉ૖ਅ̦‫ފ‬൱̱̀౷֖͈΋ηνΣΞͻ̷͈͂ਯྦྷࡢ૽ͅచ̱̀Ȃྕ଻৖ۛȂਞྎ‫ܢ‬Ήͺ̈́̓ͅ‫̱̀۾‬೹‫̳ͥރ‬΍ȜΫΑ̞̠ͬȃ! GP ͉ȂNHS ൝͂ࠀ࿩ͅ‫̧̿ܖ‬Ȃഴ჏̯̹ͦਯྦྷͬచય֓ͅၷ΍ȜΫΑͬ೹‫ٳ̳ͥރ‬ު̜֓́ͥȃGP ͈ࡢ૽‫ࠁުٳ‬ఠ͉ࡘઁ̱ȂΩȜΠ΢Ȝࠁఠ͈‫̦ࣣڬ‬௩‫̧̞̱ͥ̀̀ح‬ȃࠀ࿩ષ೰̞͛ͣͦ̀ͥ΍ȜΫᾼ͉Ȃ3 ਅ႒̜ͥȃ͉͌͂̾Ȃ஠͈̀ GP ̦೹‫ͬྩ݅ރ‬໅
̠ Essential service ́Ȃഴ჏̯̹ͦਯྦྷͅచ̳ͥȂࠑ௽എ̈́૷ၷȪྕ଻৖͉ۛ́ಿ‫ۼܢ‬͈૷ၷ̈́ͥͅȫ͞୺࿝֓Ȇພ͈֭͒તٚ൝̦‫ͥͦ͘܄‬ȃྕ଻৖ۛۛ৪ͬ community nurseͅત̳̭̜ٚͥ͂ͥ͜ȃAdditional service ͉Ȃ೹‫ܢ̦ރ‬ఞ̯̞̦ͦ̀ͥ४‫̭̞̱͂̈́ح‬̧͈́ͥ́͜͜Ȃঊ‫͈ރ‬ထཡ୪ਅ̜̈́̓́ͥȃEnhanced service ͉Ȃۛ৪͈ါ୏Ȇຈါ଻ͅ‫̠࣐̞̀̿ܖ‬۰ౙ̈́‫̜ͥ́̓̈́੅਀شٸ‬ȃ!
㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟
1999 ා̥ͣͼϋΈρϋΡ͉ȂΗΑ·έ΁ȜΑͬ୭̫̀ۛ৪͈ুࡨ‫ۯ‬ၑͬ঑‫̳ͥ׳‬
Expert Patients Programme ͈൵වͬ࠿൦̱Ȃ̷͈ࢃ 2001 ාͅ༭࣬੥38ͬ࢖ນ̱̀Ȃոြ̭͈ίυΈρθͬ৘ঔ̧̱̹̀ȃ̹͘Ȃ2000 ාయ੝͉͛ͅ NHS ̦Ȃ‫࣭ם‬஠ఘ͈ NHS৘ঔ‫ܖ‬੔ͬা̳ National Service Framework (ո‫ئ‬ȂNSF ̞̠͂) ̤̞̀ͅȂྕ଻৖ۛͬζΥΐιϋΠ̳ͥ Chronic Disease ManagementȪո‫ئ‬Ȃུ୯͉́ȂCDM ̞̠͂ȫ͈৘ঔ‫ܖ‬੔Ȇ‫ུܖ‬എ̈́ࣉ̢༷ͬা̱̹ȃ̳̻̈́ͩȂྕ଻৖͉ۛίρͼζςΉͺ͈ႀ֖̤ͅ
̞̀చੜ̧̱́ͥȂచੜ̧̳͓̜́ͥȃ΀ϋΩχȜ̯̹ͦۛ৪̦ু໦́‫ۯ‬ၑ̧̠́ͥ͢
̳ͥͅȂྕ଻৖ۛۛ৪͈ুࡨΉͺ(self-care)̦ਹါ̜́ͤȂۛ৪͈໚࿪‫ۯ‬ၑͬ঑‫̭̳ͥ׳‬͂ȂGP ͅ‫ ̢̀ح‬specialist nurses ͜ allied health professional ͜ಎ‫ړ‬എ̈́࿨‫ͬڬ‬౜̧̠̭̦̭̜͂́ͥ͂̈́̓́ͥ39ȃ
৖ພࢹ௮̦ྕ଻৖ۛ͒ΏέΠ̱̹̭͈͂͒చ؊͈̹͈͛༫‫گ‬എ̈́ଽॐജ‫̦ٳ‬Ȃྶাഎͅଽॐ໲੥̜͈͉ͣͩͦͥͅȂ2004 ා̥̜ͣ́ͥȃ༗࠲જ͉Ȃ2004 ා 3 ࠮ 3 ඾

The NHS Confederation, “The NHS handbook 2010/11”, 12th ed., The NHS Confederation,2010 .
38 Department of Health,” The Expert Patient: A New Approach to Chronic Disease
Management for the 21st Century", Department of Health, 2001.
39 Department of Health, "National Service Framework: A practical aid to implementationin primary care", Department of Health, 2002.
37

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ͅ”Improving Chronic Disease Management”40ͬ࢖ນ̱ȂίρͼζςΉͺ͈૷ၷ͈ 80ɓ͂޽‫ݢ‬ව͈֭ 3 ໦͈ 2 ͉ྕ଻৖ۛͅ‫̜͈̳ͤ́ͥ͜۾‬Ȃྕ଻৖ۛ41͉ NHS ͂̽̀ͅਹါ
̈́ଽॐ‫ه‬ఴ̞͂̈́̽̀ͥ͂੆͓̞̀ͥȃ൳໲੥͉ȂCDM ͬ٨஝̳ͥ̈́ͣ͊Ȃۛ৪ΉͺȂ΍ȜΫΑ຦ৗ͈࢜ષ̤͍͢๯ဥ୯ࡘ̦‫ܢ‬ఞ̧ܱ̱̞́ͥ͂̀ͥȃၻࢡ̈́ CDM ̽̀͢ͅ༒
‫࣐୶̹̜̦̽ף‬ম႕̱͂̀Ȃ‫ ͈࣭ם‬Castlefields Health Centre ͈ম႕Ȃༀ࣭͈ࣞႢ৪࢜
̫ case management ̜́ͥ EvercareȂప࿨߳૽ͬచય̱̹͂ CDMȂ̤͍͢ Kaiser
Permanente ͈ম႕ͬ৾ͤષ̬̞̀ͥȃచયਬ౬ͅచ̱̀ྕ଻৖͈ۛࣾඳ଻͈೾ഽ͈֑̞ͅ؊̲̹ͺίυȜΙͬ৘࣐̳ͥȂPopulation Management ͈΋ϋΓίΠͬ൵ව̱̞̀ͥȃ̭͈ Population Management ͈΋ϋΓίΠ͉Ȃల 1 ડ́৾ͤષ̬̹ Kaiser Pyramid ͂൳̲̜́ͥȃ̳̻̈́ͩȂచયਬ౬ͬ 3 ͈̾೾ഽͅ‫ٴ‬௄‫̱ا‬ȂLevel 1 ͉஠ఘ͈ 70ɓ̥ͣ
80ɓ͈૽șͅ self-management ͬ‫̳ͥ֗ޗ‬ȃLevel 2 ͉ȂΧͼςΑ·͈ۛ৪ਬ౬̜́ͤȂcare management ͬ৘ঔ̳ͥȃLevel 3 ͉ȂΧͼςΑ·́අࣾͅඳഽ̦̞ࣞۛ৪ͅచ̱
̀ࡢ༆ͅ case management ͬ৘ঔ̳ͥȃ̷͈చયਬ౬஠ఘͅచ̱̀࠲ࢫ௩ૺ͈৾ழ࣐ͬ
̠Ȫ଎ນ 2-5-1 ४ચȫȃ
ల 1 ડ́੆͓̹̠͢ͅȂ‫͉࣭ם‬ༀ࣭κΟσͬু࣭͈২ٛഎ֓ၷഎ̈́໲ྤ͈̥̈́́୆̥
̷̠̳͂ͥদ͙ͬ৘க̧̱̹̀ȃༀ࣭͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̷͉͈͈͘͘ࠁఠ́‫࣭ͅם‬൵ව̯̹͈͉̞̦ͦ́̈́Ȃఉ̩͈ത్́۟ࣸథ̯ͦ‫࣭ם‬ၠͅ٨་̯ͦ
ഐဥ̯̞ͦ̀ͥ͂ࣉ̢ͣͦͥȃ

Department of Health, “Improving Chronic Disease Management”, Department of Health,2004(visited Feb.9 2012)<http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4075213.pdf.>.
41 ྕ଻৖͉ۛȂchronic disease ͂ࡤઠ๊̯̭̦֚ͦͥ͂എ̜́ͥȃ‫ ࣭́͜ם‬chronic disease ͈ဥ༹̜̦ͥ͜Ȃlong-term conditions ͈ဥࢊ̦ဥ̞̭̦ͣͦͥ͂ఉ̞ȃ
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࿑⴫ 2-5-1 Population Management

Population management
More than care and case manegement

Level 3:Highly complex
patients
Case
management

Level 2:High risk patients
Care management

Level 1:70-80% of a Chronic CareManagement popilation

Health promotion(੄ങ)!

Department of Health, “Improving Chronic Disease Management”,

Department of Health, 2004‫͉࣭ם‬Ȃༀ࣭͈͂ΰσΑΉͺΏΑΞθ̦ఱ̧̩։̈́ͥ͂ࣉ̢̞̦ͣͦ̀ͥȂષ੆͈̤͂
ͤༀ࣭͈΋ϋΓίΠȂίυΈρθͬୟޭഎͅ൵ව̱̞̀ͥȃ̱̥̱Ȃ֓ၷ༗ࡏ৪ͅ‫̳۾‬ͥΏΑΞθͅ‫͉̱̀۾‬Ȃ႒য଻̦̜͈ͥ͂ঐഊ̜ͥ͜ȃPrimary Care Trust (ո‫ئ‬ȂPCT̞̠͂)͉Ȃ౜൚̳ͥ౷֖̦ຈါ̳͂ͥΰσΑΉͺȆ΍ȜΫΑͬ GP ൝͂ࠀ࿩̱ࣔව̱̀೹‫ ̳ͥރ‬NHS ͈ழ૕̜́ͥȃ̭͉ͦȂༀ࣭͈౷֖ͬࡠ೰̱̹ MCO(managed-careorganization)̢̧̭̦͈݀ͥ͂́ͥ͂ͅ৽ಫ̜́ͥ42ȃ̭͈௖֑͂႒য଻͉Ȃ‫࣭͂ͅם‬̽̀ༀ࣭͈΋ϋΓίΠȂίυΈρθ൵වͬૄ࠯̫̞̿̀ͥ͂ࣉ̢ͣͦͥȃPCT ͉Ȃ౜൚̳ͥ౷֖͈ਯྦྷͬచય̱͂̀Ȃ̷͈ຈါ̳͂ͥίρͼζςΉͺȂພ֭΍ȜΫΑ͈̈́̓ඵষ֓ၷ͈΍ȜΫΑͬ಺ో೹‫̳͂͂ͥ͜ͅރ‬Ȃcommunity care ͜೹‫̳ͥރ‬࿨‫ͬڬ‬౜̞̽̀ͥȃ̷़͈࡙͉‫࣭ם‬༗࠲જ̥ͣ‫ͤڬ‬൚͈̀ͣͦͥ́Ȃ‫̞ޑ‬ထॳଷ࿩̦̜̦ͥȂ֓ၷ
Robert L Kane, “Strategies for improving chronic illness care: some issues for the NHS”,
Aging Health , 3(3). 333-342, 2007.
42

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୺࿝૖ͬ‫͚܄‬৏࣐‫̦۾ܥ‬ඊু̷͈ͅ৏̧࣐̾ͅ฻౯̱̀༗࠲֓ၷ΍ȜΫΑ঩࡙͈಺ో
͂೹‫ͬރ‬৏̧࣐́ͥ43ȃ༷֚́ਯྦྷ͈࠲ࢫ̞̾̀ͅୣහͬ໅౜̳ͥঀྵ̷͈͂৏࣐ࠫ‫ض‬ͬ୰ྶ̳ͥୣහͬဓ̢ͣͦȂఈ༷́‫̞ޑ‬ထॳଷ࿩͈̥̜̹̈́ͥ͛ͅȂ΍ȜΫΑ͈຦ৗͬ࢜ષ̵̯ͥ͂͂͜ͅ঩࡙࢘ၚ଻ͬ࢜ષ̵̯ͥ‫ͼ̞ޑ‬ϋΓϋΞͻή̦ဓ̢ͣͦͥࢹ௮ͅ
̞̈́̽̀ͥȃ
௽̞̀൳ා 5 ࠮ 1 ඾ͅ༗࠲જ͉Ȃ”Chronic disease management: A compendium of
information”ͬ࢖ນ̱Ȃમळͬ୰ྶ̱̹ȃCDM ͅ‫̳ͥ۾‬ΏΑΞθͬ࠿൦̳̹͈ͥ͛ड
͜ခဥ̈́κΟσ͉Ȃల 1 ડ́୰ྶ̱̹ Chronic Care Model ̜́ͥȃNHS ͉̭͈ͅChronic Care Model ͈ါளͬ‫ͅܡ‬ခ̱̤̀ͤȂࣽࢃထ೰̯̞ͦ̀ͥ GP ͈༭ਫଷഽ٨
೰̭͈͜κΟσͅ‫ͥͦ͘܄‬ȃ̹͘Ȃ̭͈κΟσ͉Ȃତ࠯͈ࡢ༆എ̈́ CDM ͈৾ழͬ࠿
൦̳͈͉̩ͥ́̈́Ȃ֚Ⴒ͈Ⴒࠈ̱̹ۛ৪Ȇ౷֖͈͒ CDM ͈৾ழͬ࠿൦̳͈ͥͅ࿨ၛ
̱̞̾͂̀ͥ44ȃߓఘഎ͉ͅ Chronic Care Model ͬ NHS ͈ΏΑΞθͅഐဥ̱̹ࠫ‫ض‬ͬষ͈̤͂ͤ୰ྶ̱̞̀ͥȃ̴͘ȂΰσΑȆΏΑΞθ̤̫ͥͅȂΰσΑΉͺ΍ȜΫΑ͈ழ૕(health care organisation (HCO))̞̾̀ͅȂPrimary Care Trust (PCT) ͉Ȃఈ͈ NHS Trust ͞ social care ͂Ⴒࠈ̱̀Ȃൡࣣഎ̈́ΰσΑΉͺ΍ȜΫΑͬ೹‫̳ͥރ‬ຈါ̦̜ͥȃ৽̹ͥ࿚ఴ͉Ȃࣞ຦ৗ͈Ήͺ͈೹‫ͬރ‬௯ૺ̳ͥͼϋΓϋΞͻήͬ‫߸۾‬৪̦‫ވ‬ခ̧̥̜́ͥ́ͥȃুࡨ‫ۯ‬ၑͅచ̳ͥ঑‫(׳‬self management support (SMS)ȫ̞͉̾̀ͅȂ‫ ͅܡ‬NHS ̤̞̀ͅ Expert Patients Programme ൝̦৘ঔफ͙̜̦́ͥȂ̺͘໐໦എ̜́ͤȂ̯ͣͅȂ࿪स঍Ȇ࿪ޫ͜࿨‫̵̠̹ͥ͢ͅضͬڬ‬་̢̭ͥ͂͜ૺ͛ͥȃփএࠨ೰͈͒঑‫(׳‬decision support (DS)ȫ̞͉̾̀ͅȂ΀ΫΟϋΑȆαȜΑ̳͂ͥຈါ̦̜̦ͥȂNSF ͞ NICE45͈΄ͼΡρͼϋ͉ခဥ̜́ͥȃΰσΑΉͺ΍ȜΫΑ͈‫ރ‬‫ݯ‬ΏΑΞθ͈୭ࠗ(delivery system design (DSD)ȫ̞͉̾̀ͅȂఉ૖ਅ͈ΙȜθͥ͢ͅ΍ȜΫΑ೹‫ͬރ‬ίρͼζςΉͺ́৘࡛̳ͥຈါ̦̜ͤȂςΑ·͈‫ٴ‬௄‫ͅا‬؊̲̹৾ழ
̱͂̀ȂΧͼςΑ·৪ͅచ̳ͥ case management ৘ঔ͈̹͛ͅ౷֖͈ۭࢌ঍͈࿨‫ͬڬ‬‫̳ͥاޑ‬ຈါ̦̜ͥȃႉ઄ͅ‫ૂ̳ͥ۾‬༭ΏΑΞθ(clinical information system (CIS)ȫ
̞͉̾̀ͅȂྕ଻৖͈ۛۛ৪చ؊ͅ‫̱۾‬Ȃ3 ͈̾ RȪregistration, recall and review.ȫ
̦ະ‫̦̺ࠧخ‬ȂNHS ͉Ȃregistration ͉ၻࢡ̈́պ౾̞̦ͥͅȂrecall ͂ review ͉٨஝͈ဒ౷̦ఱ̧̞ȃૂ༭೒૞ܿ੅͉ȂςΑ·͈‫ٴ‬௄‫ا‬Ȃ຦ৗ‫ۯ‬ၑȂૂ༭‫ވ‬ခ͈٨஝͈̹
͛ͅ‫ڰ‬ဥ̧̳͓̜́ͥȃষͅ΋ηνΣΞͻ̤̫ͥͅ community resources (CR)̞̾ͅ
͉̀ȂPCT ͈࿨‫̦ڬ‬ਹါ̜́ͥȃPCT ͉Ȃ౜൚̳ͥ౷֖̦ຈါ̳͂ͥΰσΑΉͺȆ΍ȜΫΑͬࠀ࿩ࣔව̱̀೹‫ ̳ͥރ‬NHS ͈ழ૕̜́ͥȃPCT ͉ȂুহఘȂ౷֖͈δρϋΞͻͺ౬ఘ͂୽ၞഎ೹ࠈ‫̬̜ͥͤैͬ߸۾‬ຈါ̦̜ͥȃWhite T, “A Guide to the NHS”, p.8, p.35, 2010
Wilson, T et al, "Rising to the challenge: will the NHS support people with long term
conditions?” BMJ 330, 657-661, 2005.̤̞̀͜ͅȂNHS ͈͒ഐဥ͈໦ଢ଼̦࣐̞ͩͦ̀ͥȃ45 The National Institute for Health and Clinical Excellence (NICE) ͉Ȃ
1999 ͅ୭ၛ̯̹ͦȂ
NHS ͈ඊၛ‫́۾ܥ‬Ȃ΀ΫΟϋΑȆαȜΑ͈΄ͼΡρͼϋͬैୋ̱̞̀ͥȃ
43
44

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2005 ා 1 ࠮ͅ༗࠲જ͉Ȃ౷֖΋ηνΣΞͻ̤̫ͥͅͼΦαȜΏοῧΰσΑΉͺ΍! !

ȜΫΑ͈ൡࣣͬ଎ͥଽॐͬ୰ྶ̱̹໲੥̜́ͥȂ”Supporting People with Long Term
Conditions. An NHS and Social Care Model to support local innovation andintegration.”46ͬ࢖ນ̱̹ȃ̭̭́೹া̯̹͈̦ͦȂ֓ၷ΍ȜΫΑ͂ social care ͬൡࣣ̱̀ྕ଻৖ۛͬခ̳ͥ૽șͬ঑‫̳ͥ׳‬κΟσ̜́ͥȃ̭͈κΟσͬ଎া̱̹͈̦Ȃ଎
ນ 2-5-2 ̜́ͥȃ࿑⴫ 2-5-2 The NHS and social care long term conditions model

The NHS and social care long term conditions model
Infrastructure

Delivery System

Community
Resources

Health and social
care system
environment

DiseaseManagement

Supported
Self care

Creating

Case
Management
Supporting

Decision support
tools and clinicalinformation
system (NPfIT)

Better outcomes

Empoweredand informed
patients
prepared andproactive
health and social
care teamsȪ੄ങȫDepartment of Health, “Supporting People with Long Term Conditions. An NHS

and Social Care Model to support local innovation and integration”, Department of
Health, 2005.
NHS and Social Care model ͉ȂChronic Care Model ͬͼϋΈρϋΡ͈৘ఠ͂ଽॐജ
‫̵ࣣ̀ͩͅٳ‬٨་̱̹͈͂͜ၑ̧ٜ̳̭̦ͥ͂́ͥȃDelivery system ͉ȂPopulation
Management ͈२௄ࢹ௮ͬা̱̞̀ͥȃ̭͈κΟσ͈ါത͉Ȃո‫̜̤͈ͥ́ͤ͂ئ‬ȃӱ֓ၷȂsocial care, ۛ৪ȂΉͺ΍ȜΫΑ೹‫ރ‬৪(career)ͬςϋ·̵̯̹ΏΑΞθഎͺίυȜΙȂӲྕ଻৖ۛͬခ̳̜ͥͣͥ͠૽ͬඅ೰̳ͥȂӳ ૽ș̷͈ͬΣȜΒͅ؊̲̀‫ٴ‬௄‫ا‬̳ͥȂӴඵষ֓ၷͬອ้ͅ၌ဥ̳ͥ৪ͅઙതͬ൚̀ͥȂӵcase management ͬ৘ঔ̳ͥ

Department of Health, “Supporting People with Long Term Conditions. An NHS andSocial Care Model to support local innovation and integration”, Department of Health,

46

2005.

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̹͈͛΋ηνΣΞͻۭࢌ঍ಿ(Community Matron)47ͬ൵ව̳ͥȂӶඅͅఱၾ͈૬࣫̈́΍ȜΫΑͬຈါ̳͂ͥ৪ͬඅ೰༹̳༷ͥͬ‫ٳ‬อ̳ͥȂӷspecialist advice ͅ‫̧̿ܖ‬ఉ૖ਅ͈‫ވ‬൳̳ͥΙȜθͬ༎଼̱̀৘ঔ̳ͥȂӸself care ͬ঑‫̳ͥ׳‬౷֖ඊু༹͈༷ͬ‫ٳ‬อ̳ͥȂӹ ਲ ြ ̥ ͣ ৘ ঔ ̱ ̀ ̞ ̹ Expert Patient Programme ̷ ͈ ఈ ͈ self-management
programme ͬ‫ڐ‬ਰ̳ͥ(̤̈́Ȃ଎ນ 2-5-2 ͈ disease management ͉Ȃcare managementͅ‫ڂ‬൚̳ͥȫȃ!
㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߩ⃻⁁ߣ᡽╷⺖㗴‫ ͈࣭ם‬CDM ̤͍͢, NHS and Social Care model ̦࿒ঐ̳࿒ດ͉̞̩̾͜ࠇ̬ͣͦ̀
̞̦ͥȂ̷͈࿒ດ͈͉͌͂̾Ȃ࢘ၚ଻Ȇ΍ȜΫΑ຦ৗ͈٨஝̜́̽̀Ȃౙ̈́ͥ๯ဥ͈୯
ࡘ͉̞́̈́ȃ࢘ၚ଻Ȇ຦ৗ٨஝͈৾ழ͉အș̈́ࠁఠ́ജ‫̞̯ͥ̀ͦٳ‬ȃNHS ͈‫۾‬Ⴒழ૕̱͂̀ Health Enterprise East Limited (HEE) ̦̜ͤȂ‫ڟ‬૧എ̈́΍ȜΫΑȆίυΈρθ
‫ٳ‬อͬ೒̱̀ȂNHS ͈࢘ၚ଻Ȇ຦ৗ٨஝࣓ͅࡃ̳̭ͥ͂ͬঀྵ̱̞͂̀ͥȃ̷͈ HEE͉ȂSBRI (Small Business Research Initiative) East ͬജ‫̤̱ͤ̀ٳ‬Ȃ2011 ාͅ
Improving the Health of People with Long-Term Conditions ‘Personalisation andEmpowerment’͂ఴ̳ͥȂ‫އ‬௔වढ़ͬ৘ঔ̱̹ȃ̷͈෸ࠊ୰ྶ໲੥͉́ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈΋ΑΠ࢘ၚ଻ͅ‫΀̳ͥ۾‬ΫΟϋΑ͉̺͘ࡠ̞͈ͣͦ̀ͥ́Ȃ‫ڟ‬૧എ̈́ίυΈρθ͈؊༡ͬ‫̱͂ͥ͛ݥ‬Ȃ࢘ၚഎ̈́ΰσΑΉͺ̦‫̞̯ͥ̀ͦ಺ޑ‬48ȃ
ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐജ‫̠͈͙̱̓͂ͥ̀͂͢ͅٳ‬̧ٜ̳̭̦̺̠̥ͥ͂́ͥͧȃ̴͘Ȃ̭̓ͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦̜̥͙ͥͬͥ͂Ȃ৘ঔ৽ఘ̦ GP ̜́ͤȂpopulation ͂̈́ͥచય৪͉Ȃഴ჏̯̹ͦਯྦྷ̜́ͥ
ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͂ȂPCT ̦৘ঔ৽ఘ͂̈́̽̀చય̳͂ͥਯྦྷͅచ
̱̀ population management എอே́৘ঔ̳ͥ΍ȜΫΑͬ৽ఘ̳͂ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ඵ̦̾ࣉ̢ͣͦͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃಿ‫ܢ‬എ̈́ଽॐْ̜̞͉ࠗͥ! ஠ఘഎْ̈́ࠗͬ৘࣐̳ͥषͅဥ̞ͣͦͥ਀౲͈̜͌͂̾́ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ̱͂̀ॐ೰ജ‫͉͈̞̯̈́́ͥ̀ͦٳ‬̞ȃ
2006 ා 3 ࠮‫ ͈࣭ם‬King’s Fund ̦Ȃ‫ם‬ༀ͈ CDM ͬ๤‫࠿ڛ‬൦̱̹Γη΢Ȝ̤̞̀ͅȂ‫ם‬ༀ͈ΏΑΞθȆ۪‫͈ޏ‬௖֑͉̜̦ͥȂၰ࣭‫ވ́ۼ‬ခ̯̹ͦࠫა̱͂̀Ȃ։̈́ͥ൚ম৪
़͈ଽഎ̈́ͼϋΓϋΞͻή͈୭̦ࠗਹါ̜̭́ͥ͂Ȃૂ༭೒૞ΏΑΞθ͈‫ڰ‬ဥȂఉ૖ਅ‫ފ͈ۼ‬൱ͬ৘࡛̳ͥȂ֓঍̷̜̞͉͈ͥఈ͈༗࠲૖͈ςȜΘȜΏΛί̦ਹါ̜̭́ͥ͂

47֓ၷࠐफࡄ‫ࢹܥݪ‬ȶͼΆςΑ֓ၷ༗વଷഽͅ‫಺̳ͥ۾‬औࡄ‫ݪ‬༭࣬੥Ⱥ2009 ාๅȻȷ֓ၷࠐफࡄ‫ !ࢹܥݪ‬2010 ͅࠇश̯̞ͦ̀ͥ࿫ࢊͬဥ̞̹ȃ48 Technology Strategy Board , Competition for development contracts “SBRI East -Improving the Health of People with Long-Term Conditions Personalisation andEmpowerment” (accessed 9, February,2012)<http://www.innovateuk.org/_assets/
new%20assets%202nd%20feb%202011/sbri_east_2011%20brief.pdf>.
-43-̜̈́̓́ͥ49ȃ
! 2008 ාͅട̹͛ͣͦȂ؎ਗ 8 ΃࣭͈ CDM ͅ‫̳ͥ۾‬ଽॐ໦ଢ଼͈ࡄ‫͉́ݪ‬ȂͼϋΈρϋ
Ρ̞̾̀ͅষ͈̤͂ͤঐഊ̱̞̀ͥȃ̷͈ଽॐ͈৽̈́ઙത͉Ȃໝॠ̈́ΣȜΒͬ༴̢ͥۛ
৪ͬ‫ۯ‬ၑ̳̭ͥ͂ͤ֓͢ͅၷ΍ȜΫΑ͈၌ဥͬड઀ࡠͅဲଷ̱ȂΉͺͬພ̥֭ͣ౷֖֓
ၷ̹͉֚͘ষ֓ၷঔ୭ͅ֊̵࣐̯̭̜ͥ͂́ͥȃ̯ͣͅȂ࡛हૺ࣐ಎ͈ CDM ͅ‫̳ͥ۾‬ଽॐജ‫ͤ৾ͅٳ‬ழ̞ͭ́ͥඤယͬո‫̤͈ͤ͂ئ‬ါ࿩̱̞̀ͥȃ̳̻̈́ͩȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥΑΗΛέူ଼͒ൎ঩̱̞̭̀ͥ͂Ȫߓఘഎ͉ͅȂΑΗΛέ͈૧̹̈́࿨‫ٳ͈ڬ‬อȂ߱ႯȆෝႁ‫ٳ‬อ͈იழ̩̿ͤȂ̤͍͢ࢩํ̈́ΑΗΛέͬ‫ۑ‬ည̳̹͈ͥ͛ͼϋΓϋΞͻήΏΑΞθͬनဥ̱̹ GP ̤͍͢࿪स঍͈͂ࠀ࿩༷৆͈नဥȫȂͼΦαȜΏοϋͬ঑‫̭̞̱͂ͥ̀׳‬Ȫ૧̱̞κΟσͬ৘౷࠿બ̳ͥΈσȜίͬ୭౾̱Ȃ౷֖̤̞̜̞͉࣭̀ͥͅषഎ̤̞̀ͅං̹ͣͦ΀ΫΟϋΑȆαȜΑ͈౶ࡉͬอນ࢐̳۟
̭ͥ͂̈́̓ȫ
Ȃૂ༭ΏΑΞθͬ‫ٳ‬อ̱̞̭̀ͥ͂Ȫsocial care ͜‫̹͛܄‬஠࣭τασ͈ૂ༭‫ވ‬ခঔॐ̈́̓ȫȂুࡨ‫ۯ‬ၑ͈঑‫͂׳‬΍ȜΫΑْ̦ࠗȆ৘࣐Ȇບ‫̯ͥͦث‬ष͈΍ȜΫΑ၌ဥ৪͈࿨‫͈ڬ‬ਹါ଻ͬਹণ̳ͥ৾ழ̱̞̭ͬ̀ͥ͂ȪExpert Patient Programme, ̷͈ఈ΍ȜΫΑ͈၌ဥ৪̦ထॳͬ‫ۯ‬ၑ̳ͥॽழ͙̈́̓ȫ̜́ͥȃ̭͈ঐഊ̥ͣȂଽॐ‫ه‬ఴ̱͂̀Ȃӱ‫߸۾‬৪͈ୟޭഎ४ْͬ௯̳৾ழȂӲࠐࡑ౶͈࢐ၠ͈ॽழ͙Ȃӳૂ༭‫ވ‬ခͼϋέρ͈ା๵ȂӴͼϋΓϋΞͻήΏΑΞθ͈डഐ‫ا‬୭̜̬̞ࠗͬ̀ͥȃ

Rosen R et al, “IMPROVING CHRONIC DISEASE MANAGEMENT”, King’s Fund, 2007.
Nolte E et al, “Managing chronic conditions: Experience in eight countries”, European
Observatory on Health Systems and Policies, 2008.

49
50

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╙  ▵ ࠞ࠽࠳㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊! ӱ࣭͈අಭȆ‫ڟ״‬΃΢Θ(Canada)͉Ȃ࿂ୟ 9,984,670 ໹༷΅υιȜΠσȪ඾ུ͈ 26.4 ෼ȫȂ૽࢛ 3,434
ྔ 9,236 ૽Ȫ2011 ා 4 ࠮ 1 ඾শതȂଔࠗ౵Ȃ੄ਫ਼ȇ΃΢Θൡࠗޫȫ̜́ͥȃࢩఱ࣭̈́ാ
ͅ 3000 ྔ૽‫ݳ̦ޑ‬ਯ̱̞̀ͥȃ! ! ΃΢Θ͉ȂႲཆଷ̜́ͤȂ10 ͈ਗȪprovinceȫ͂ 3 ͈̾੔ਗȪterritoryȫ̦̜ͥȃडఱ͈ਗ͉΂ϋΗς΂ਗ̜́ͥȃႲཆଽຸ͉Ȃ࣭ཡȂ‫࢐ٸ‬Ȃ࣭ඤ‫͈ٸ‬೒੸͂ཟօȂ֊ྦྷȂ߆࣐Ȇ߄ဏଷഽȂߺ༹Ȃ‫̱ڵۯͬ̓̈́ުݽ‬Ȃਗ̤͍͢੔ਗଽຸ͉Ȃ‫֗ޗ‬Ȃव฻ਫ਼Ȃພ֭Ȃਗඤ͈ഛட঩࡙Ȃ২ٛ༗વȂ֓ၷ̤͍͢౷༷ুহఘଷഽ̈́̓ͬ‫̳ͥڵۯ‬ȃӲΰσΑΉͺΏΑΞθȪ೹‫ރ‬ఘଷ़࡙͂಺ో༹༷ȫ͈අಭ͂་஗
! ΰσΑΉͺͅ‫͉ڵۯ̳ͥ۾‬ਗ̜́ͥȃ̱̥̱ȂႲཆ͉ਗͅచ̳ͥ‫׳‬੩൝̽̀͢ͅ৘ৗ
എͅ૬̩‫۾‬ဓ̱̞̀ͥȃ࡛ह΃΢Θ͉Ȃ̳͓͈̀ਗ̤̞̀ͅਗ̦஠ਗྦྷͅచ̱̀ࢩํս
͈֓ၷ༗વͬ೹‫ ̳ͥރ‬Medicare51͈ΏΑΞθ̦৘ঔ̯̞ͦ̀ͥȃ̷़͈࡙͉Ȃ़๊࡙̜֚́ͤȂ֓‫ڠ‬എͅຈါ̈́֓ၷ΍ȜΫΑ(medically necessary services)̞͉̾̀ͅȂ਋૷শͅࡔ௱എۛͅ৪໅౜͉̞̈́ȃMedicare ͈อ௷ͅঢͥႤঃͬ૦ͤ༐ͥ͂Ȃ1947 ාͅ΍Α΃Ινχϋਗ̦ව֭๯ဥͬచય̳͂ͥພ֭༗ࡏଷഽͬ൵ව̱̹̭͂ͅইͥ͘Ȫ൳ਗ͉
1962 ා֓ͅ঍͈๯ဥͬచય̳͂ͥ֓ၷ༗ࡏଷഽͬ൵ව̱̹ȫȃ΍Α΃Ινχϋਗͅ௽̧Ȃఈ͈ਗ͜൳အ͈ଷഽͬ൵ව̱̞̹̀̽ȃ1957 ාͅၛ༹̯̹ͦ Hospital Insurance andDiagnostic Services Act ͅ‫̧̿ܖ‬ȂႲཆଽຸ͉ਗଽຸ͈໅౜̳ͥ๯ဥ͈֚໐ͬ໅౜̱̹ȃ̷͈ࢃȂႲཆଽຸ̦‫ڎ‬ਗ͈͂‫ފ‬೰൝ͅ‫̧̿ܖ‬໅౜̳ͥଷഽ͉Ȃ႕̢͊ 1995 ා̥͈ͣCanada Health and Social Transfer (CHST)̈́̓ͬࠐ̀Ȃ࡛ह͜ࠑ௽̯̞ͦ̀ͥȃႲཆଽ़ຸ͈࡙໅౜͂ਗȆႲཆଽຸ͈‫݈̀̽͢ͅފ‬Ȃ‫ڎ‬ਗ̦৘ঔୣහͬ໅̠ Medicare ̦Ⴒཆ஠ఘ̱͈͂̀ൡ֚എଷഽ̱͂̀‫׋‬ဥ̯ͦͥȃ
Medicare ͉ȂPrimary Health Care ServiceȂSecondary Services ͬ೹‫̳ͥރ‬ȃPrimary
Health Care Service ͉Ȃඵ͈̾‫ܥ‬ෝͬခ̱̞̀ͥȃ͉͌͂̾ȂΰσΑΉͺ΍ȜΫΑͬ਋̫ͥड੝͈୪૘୶̜̭́ͥ͂Ȃ̠͉͌͂̾ͤ͜͢୺࿝എ̈́ΰσΑΉͺ΍ȜΫΑͬ਋̫̠ͥ͢ͅત̳̭̜ٚͥ͂́ͥȃ૷ၷਫ਼Ȃcommunity health centre ͈֓঍Ȃۭࢌ঍̷͈ఈ͈༗ ࠲୺ ࿝૖̦ ΍Ȝ ΫΑͬ ೹‫̳ͥ ރ‬ȃ ྦྷ‫֓ ͈ުٳ ۼ‬঍ ͉ͅȂ ๊֚ എ͉ͅ ੄ြ ࣞ ໡ ̞Ȫfee-for-serviceȫ͈ఘࠏ́༭ਫ̦঑໡ͩͦͥȃ༭ਫ঑໡͈‫ܖ‬੔͉ȂਗȆ੔ਗ൚ޫ͈͂࢐
ખ́ࠨ೰̯ͦͥȃSecondary Services ͉Ȃພ֭Ȃٚࢌঔ୭̹͉͘΋ηνΣΞͻ́೹‫̯ރ‬ͦͥ୺࿝എ̈́Ήͺ̜́ͥȃພ͉֭ȂਗȆ੔ਗ൚ޫ̥ͣ਋̫৾ͥා‫͈ۼ‬༫‫گ‬ထॳͬ਋̫৾
̽̀‫๊̦̭̳֚͂ͥא׋‬എ̜́ͥȪ೏‫͈ح‬঑໡࣐̠ͬਗ̜ͥ͜ȫȃພ֭‫͈ٸ‬ੜ༷࿪सȂভ

51ༀ࣭͈ιΟͻΉͺ͂൳֚೜̜̦ͤ́ͥȂ༆͈͈̜́ͥ͜ȃ΃΢Θ̤̞̀ͅȂༀ࣭͈ιΟͻΉͺ͂ߊ໦̳̹ͥ͛ͅఱ໲লͬঀ̽̀ Medicare ͬນܱ̳̭̦̜ͥ͂ͥȃུ୯͉́Ȃ̭ͦͅ༩̞
Medicare ͂ນܱ̳ͥȃ-45-‫૷ش‬ၷ͉ࡔ௱എͅచય‫̜ͤ́ٸ‬Ȃ၌ဥ৪͈জ๯໅౜́঑໡̠̥ྦྷ‫ۼ‬༗ࡏͬ၌ဥ̳̭ͥ͂
̈́ͥͅȃ1984 ා͈ Canada Health Act ͉ȂιΟͻΉͺ 5 ࡔ௱ͬܰ೰̱̞̀ͥȃ̳̻̈́ͩȂӱPublic Administration ࢖എͅ‫ۯ‬ၑȆ‫̭̯͂ͥͦא׋‬ȂӲComprehensiveness ༫‫گ‬എ̈́֓ၷ΍ȜΫΑ͈೹‫̱̺̹(̭̜͂ͥ́ރ‬Ȃ๊֚എ̈́ভ‫ش‬হၷ൝͉ੰ‫ٸ‬ȃພ֭ඤ͈ভ‫ش‬হၷ͉‫)͚܄‬ȂӳUniversality:ຽ༑എ̳͓͈̀ͅਗྦྷͅచ̱̀൳̲ૄ࠯́ഐဥ̯̭ͦͥ͂ȂӴ
Accessibility:ࣣၑഎ́֓‫ڠ‬എͅຈါ̈́ (medically necessary ) ພ֭Ȇ૷ၷਫ਼΍ȜΫΑ̦߄஘എ໅౜̷͈ఈ͈વ‫̱̈́ͅٺ‬਋̫ͣͦͥȂӵPortability ਗ‫́͜ٸ‬਋‫̦ࡀݯ‬༗વ̯ͦͥ
̭̜͂́ͥȃ
! ! ΃΢Θ͉ༀ࣭͈ႋ࣭̜̦́ͥȂༀ࣭͉͂։̈́ͤΟͻΐȜΒζΥΐιϋΠȆίυΈρθ
ͬ৘ঔ̳ͥ΍ȜΫΑমު৪͉ంह̱̞̈́ȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥ৘࣐৪͉Ȃ֓ၷ‫߸۾‬৪ু૸̈́ͥͅȃίρͼζςΉͺͬ౜̠֓঍͉Ȃprimary care
physicianȪո‫ئ‬ȂPCP ̞̠͂ȫ͂ઠ̯̞ͦ̀ͥȪgeneral practitioner ̹͉͘ GP ͂͜ࡤ͊ͦͥȫ‫ز‬ೳ̜֓́ͥȃPCP ͉Ȃඅ೰͈৖ۛͬ୺࿝̳͈̩ͥ́̈́ͅࠑ௽എۛͅ৪͙ͬ
ͥ‫ز‬ೳ͈֓‫ܥ‬ෝͬခ̱Ȃࠚഽ͈ࣞࠬգ͞ࠚഽ͈ൠෂພ͈̈́̓ྕ଻৖͈ۛ૷ၷȂထཡ࣐͜
̞̽̀ͥ52ȃਲ̽̀Ȃྕ଻৖ۛచॐͬ৘ঔ̳ͥાࣣ͉ͅȂ̭͈ PCP ͈࿨‫ͬڬ‬ਹণ̳ͥ͂
͂͜ͅ‫߸۾‬৪͈‫ފ‬൱̦ະ‫ͥ̈́ࠧͅخ‬ȃ̭͈ PCP ͬಎ૤ͅ Montague ฎআ̦೹੹̳ͥۛ৪
ల֚Ȫpatient firstȫ͈ၑැ̹̾ͅΉͺΆλΛί(care gap)͈‫ٽ‬ැ53ͬဥ̞̹৘க႕̦̜ͥȃΉͺΆλΛί͉͂Ȃӱະഐ୨̈́૷౯ȂӲະഐ୨̈́ੜ༷Ȃӳະഐ୨̈́΋ϋίρͼͺϋΑ̤͍͢Ӵະഐ୨̈́ͺ·ΓΆ̜ͥȃ൳ฎআ͉Ȃ̭͈ΆλΛίོ͈̦ͬ͛ͥȂ֓ၷ͈ৗ͈࢜
ષͬ࿒ঐ̳ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̜̱̞́ͥ͂̀ͥȃ̭͈৘க႕̱͂̀ȂΦΨȆΑ΋Ξͻͺਗ́ Improving Cardiovascular Outcomes in Nova Scotia(ICONS)͂
ྴັ̫̹ͣͦίυΐͿ·Π̦̜ͥȃ̭͈ίυΐͿ·Π͉Ȃ1997 ා̥ͣ 5 ΃ාْࠗ́৘ঔ
̯̹ͦদ࣐৘கȪinitiativeȫ̜̦́ͥȂ଼ࢗͬਓ̹͈͛́ 2002 ා̥ͣଽຸ̦৘ঔ̳ͥম
ުͅनဥ̯ͦȂCardiovascular Health Nova Scotia (CVHNS)͂٨ઠ̯ͦࠑ௽̱̞̀ͥ54ȃ̭͈͕̥ȂΉͺΆλΛίͅ‫̩̿ܖ‬ίυΐͿ·Π͉Ȃ̷͈ఈ͈ਗ́͜৘க̯̹ͦȃ଼͈ࢗ෸ࠊͅȂ֓঍Ȃۭࢌ঍̦ಎ૤͂̈́̽̀֓ၷ͈ৗͬ٨஝̳̭ͥ͂ͬ࿒ঐ̳֓ၷ৪৽൵͈৾
ழո‫ͅٸ‬Ȃۛ৪ȂଽຸȂୋ࿪ٛ২͈͂ΩȜΠ΢ȜΏΛί̦‫ܥ‬ෝ̱̹̭͂͜ါ֦͂̈́̽̀
̞ͥ͂ࣉ̢ͣͦͥȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟! ! ΃΢Θ̤̞̀ͅ 2000 ාయͅ‫͈ܢ଻ݢ‬ΰσΑΉͺΏΑΞθ̦৖ພࢹ௮་‫ͅا‬చ؊̴̧́Ȃ
Primary Health Care ΏΑΞθ͈٨‫̦ڟ‬ຈါ̜͈́ͥ͂෇ে̦̩̞̹ࣞ̈́̽̀̽ȃ΃΢
Thompson V, “Health and health care delivery in Canada”, 2010,p.239.
Montague T, “Patient First: Closing the health care gap in Canada”, 2004, p.35.
54 Department of Health and Wellness, Government of Nova Scotia,
52
53“CARDIOVASCULAR HEALTH NOVA SCOTIA NETWORKMEETING: MEETINGREPORT”, June 8th and 9th,
2007,<http://www.gov.ns.ca/health/cvhns/CVHNS_NetworkMeeting_June_07.pdf>.
-46-Θ૽͉ΰσΑΉͺ΍ȜΫΑ̦ຈါ͂̈́ͦ͊Ȃ̴͘‫ز‬ೳ̜֓́ͥ PCP ͬང࿚̱Ȃ‫ز‬ೳ͉֓ຈါ̈́૷ၷ࣐̠̥ͬ୺࿝֓ͅત̴̳̥͈̞̥࣐̹ٚͥͦͬ̽ȃ̭͈ episodic, responsivemodel ͉Ḁ͉̠̩̑̾̀͘‫ܥ‬ෝ̱̹̦Ȃ࡛ह͉́ࣞႢ‫ا‬Ȃྕ଻৖ۛᑋۛၚ͈௩‫̠̞͂ح‬་‫ͅا‬చ̱̀Ȃ႕̢͊ྕ଻৖ۛͬထཡ̳͉ͥͅȂఉအ̈́ܿෝ͈ਬࠫȂۛ৪ু૸͈४ْ࢜
ષ͈̈́̓૧̱̞ͺίυȜΙȆ૧̱̞κΟσ̦‫ࡉ͈̞͂ͥ̀ͦͣ͛ݥ‬ٜ̦ນྶ̯̞ͦ̀ͥ55ȃ
! ! ̭͈ίρͼζςΉͺ٨‫͈ڟ‬අಭ͉Ȃ၌ဥ৪ͅచ̳ͥ༫‫گ‬എ̈́΍ȜΫΑ೹‫̠࣐ͬރ‬ΙȜθȆͺίυȜΙ͈͒ΏέΠ̜́ͥȃΙȜθȆͺίυȜΙ͉Ȃ‫ز‬ೳ֓Ȃۭࢌ঍̦̈́̓‫ފ‬൱̱̀Ȃૂ༭೒૞ܿ੅ͬ‫ڰ‬ဥ̱޽‫ݢ‬ང࿚͈ࡘઁ̈́̓ͬ೒̱̹࢘ၚഎ́ࣞ຦ৗ͈΍ȜΫΑͬ೹‫ॽ̳ͥރ‬ழ͙̜́ͤȂ࠲ࢫ௩ૺȆྕ଻৖ۛచॐͅఱ̧̩‫ܙ‬ဓ̳͈ࣣͥ͂փ̦̜̹̽ȃ̷͈٨‫ڎͬڟ‬ਗ̦‫ͅڲ׫‬৘ঔ̳̠ͥ͢ͅȂႲཆଽຸ͂ਗଽຸ͈‫ފ‬೰ͅ‫̩̿ܖ‬ȂႲཆଽຸ͈‫׳‬੩ந౾̦৘ঔ̯̹ͦȃ
2000 ා̥ͣίρͼζςΉͺ٨‫͈ڟ‬൲̧͉ྶ‫̹̽̈́ͅږ‬ȃ2000 ා 9 ࠮Ⴒཆଽຸਉ௖͉ȂႲཆଽຸ͂ਗଽຸ͈‫ފ‬೰ͅ‫ ̹̞̿ܖ‬Primary Health Care Transition Fund (PHCTF)͈
஻୭ͬอນ̱̹ȃ2000 ා̥ͣ 2006 ා́͘ 8 ‫΃ؙ‬΢ΘΡσͬ‫̱੄ݶ‬ȂਗȆ੔ਗ͈‫߸۾‬৪̦Ȃ૧̱̞ίρͼζςΉͺ͈κΟσ(႕̢͊ΙȜθαȜΑ͈Ήͺ೹‫͈̹͈߱͛ރ‬ႯȂૂ༭ΏΑΞθ͈ࢹಃ̈́̓ȫͅ֊࣐̳͈ͥͬ঑‫̹̱̳͂ͥ׳‬ȃ̷͈ࠫ‫ض‬Ȃ‫ڎ‬ਗ̷̸͉ͦͦඊু
ͅอജഷષ̜ͥͅκΟσࢹಃ৾ͤͅழ͚‫׳‬੩ͬං̀৾ͤழ̺ͭȃ̷͈ࠫ‫͉ض‬Ȃ৾ͤ͂͛ͣͦ͘࢖ນ̯̞ͦ̀ͥ56ȃ
! ! ΂ϋΗς΂ਗ͉Ȃ2006 ා 4 ࠮ͅ National Chronic Disease Management in Primary
Health Care Conference ͬ‫ٳ‬ट̱Ȃ‫ڎ‬ਗȆ੔ਗ͈৾ழ͈ࠐࡑͬ࢐ၠ̳ͥ‫ܥ‬ٛͬै̹̽ȃ̷͈শ͈ܱ჏͉Ȃ੄ๅ̯̞ͦ̀ͥ57ȃ
΂ϋΗς΂ਗ͉Ȃ2007 ා 5 ࠮ͅ࠲ࢫٚࢌજ̦Ȃྕ଻৖ۛచॐͬ৘ঔ̳ͥ༫‫گ‬എ̈́έτȜθχȜ·ͬ࢖ນ̱̞̀ͥ58ȃ̭͈έτȜθχȜ·͉ȂChronic Care Model ̥ͣ੄อ̱Ȃ΃΢Θ͈୶ૺ৾ழͬ४ચ̱̀Ȃ΀ΫΟϋΑȆαȜΆട̹͈̜̱̞͛́ͥ͂̀ͥ͜ȃ̷͈ඊু଻͉Ȃ΂ϋΗς΂ਗ͈࡛৘ͅഐࣣ̳̠ͥ͢ͅழ͙ၛ̹̀ͣͦȂLogic Model ̜́ͥȪ଎ນ 2-6-1 ४ચȫȃυΐΛ·ȆκΟσ͈අಭ͉, Component ͬྶা̱ȂOutput, ౣ‫ܢ‬ಎ‫ܢ‬ಿ‫ ͈ܢ‬Outcome ͅ໦̫̞̀ͥത̜́ͥȃ

Primary Health Care Transition Fund, “Chronic Disease Prevention and Management”,
Primary Health Care Transition Fund, 2007.
56 Primary Health Care Transition Fund, “Summary of Initaiatives-Final Edition”,
Ministry of Health, 2007<http://www.healthcanada.gc.ca/phctf>
57 Dorland J and McColl M A, “Emerging approaches to chronic disease management inprimary healthcare”, McGill-Queen's University Press, 2007.
58 Ministry of Health and Long-Term Care, “Preventing and Managing Chronic Disease:
Ontario Framework”, Ontario, Canada, 2007.
55

-47-

࿑⴫ 2-6-1 Logic Model for Ontario's Chronic Disease Prevention and Management
Framework

Logic Model for Ontario's Chronic Disease
VisionAn integrated, coordinated system for the prevention and management of chronic diseases, withorganizations/providers, that are proactive, individual and family-centred, and that

Inputs

Policy, Legislation/Regulations, Guidelines,

Components

Outputs

Activated Communities and Prepared, Proactive Partners








Short-term
outcomesIntermediateoutcomesLong-term
outcomes

Communities collaborating with HCOs to identify
and prioritize issues affecting the health of the
population.
Communities championing activities for healthy
public policy, and supportive environments.
Community collaboration with HCOs to develop,
link and coordinate services and information for
individuals and families.
Community information and programs integrated
with health care services.

Informed, engaged individuals and families








Education, counselling, behaviour modification programs, andinformation for individuals and families to build skills forhealthy living and coping with disease.
Tools for individuals and families to become daily selfmanagers and communicate with providers.
Care teams with individuals and families at the centre, andengaged in decision making and care planning.
Self-management information and resources accessible andtailored to meet the needs of individuals and families.
Community programs and resources integrated into care.

Increased community collaboration with HCOs to
identify and prioritize issues affecting health.
Increased community action for healthy public
policy, supportive environments to meet the needsof their population.
Increased awareness, linkages and referral tocommunity programs, information, and resources.

 Individuals and families have increased skills and knowledge forhealthy behaviours.
 Individuals, families and providers have improved
understanding of their roles as partners on care teams, andconsumers are involved in care planning.
 More individuals and families have increased knowledge of theirdisease processes and role as daily self-manager.
 Increased knowledge and skills of consumers in selfmanagement.
 More individuals and families are aware of and linked tocommunity programs and resources.

Improved healthy public policies and supportive
environments.
More community information and programs
integrated with health care services.

 More people exhibiting healthy behaviours
 Individuals and families at the centre of the care team, actively
engaged in decision-making, and daily managers of their health.
 More individuals and families gaining benefits throughinvolvement in self-management
 Increased participation in community programs and resources Increased overall satisfaction of individuals and families with the
responsiveness of the health care system to meet their needs

Improved Clinical Outcomes

Reduced burden of Chronic DiseaseȪ੄ങȫMinistry of Health and Long-Term Care, “Preventing and Managing Chronic

Disease: Ontario Framework”, Ontario, Canada, 2007-48-

Prevention and Management Framework
productive interactions and relationships among individuals/families, communities, and health careprovides access to quality care by the right provider at the right time in the right place

VisionFiscal and Human Resources, Information Systems

InputsComponents

Prepared, proactive practice teams




















Health promotion, primary, secondary, and tertiary prevention incorporated into care.
Visible leadership, aligned incentives, policies, resources, measurement, and accountability for
CDPM system changes.
Interdisciplinary team practices, with links to specialists, where health care providers
collaboratively provide patient-centred care in a seamless and coordinated manner.
Integrated electronic information systems with comprehensive, accurate information forproviders and individuals to share information & make the best decisions.
Evidence-based tools for prevention, assessment and management incorporating plannedinteractions, and prompts for follow-up.

Outputs

Providers have increased knowledge, skills and tools to incorporate prevention into theirpractices.
More HCOs promote system change and provide incentives, align policies, resources,
measurement, and accountability.
Increased number of interdisciplinary teams, with links to specialists working collaboratively andproviding coordinated, patient-centred care.
More providers using electronic information systems and sharing information among teammembers, their clients, other health providers and settings.
More providers using evidence-based tools, and quality improvement approaches for prevention,assessment and management.

Short-term
outcomes

Health promotion and prevention integrated across continuum of care.
Health care coordinated across the continuum of care, providers and settings.
The appropriate type and number of health care providers working in collaboration to meet theneeds of the individual and family.
Care is evidence based and meets the diverse needs of consumers.
Care is proactive, and provides for complex and continuing care, with follow-up and ease ofnavigation.
Integrated information systems with consumer, decision support and community information.

Intermediateoutcomes

Improved sustainability of the health system

Long-term
outcomes-49-㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߩ⃻⁁ߣ᡽╷⺖㗴
2006 ා 4 ࠮ͅ‫ٳ‬ट̯̹ͦȂNational Chronic Disease Management in Primary
Health Care Conference ͬ௙‫̱̀گ‬ȂJohn Dorland ͂ Mary Ann McColl ͉Ȃষ͈̭͂ͬଔ੻̱̞̀ͥ59ȃȆChronic Care Model, Kaiser Triangle ൝͈ framework ͈၌ဥ͉ခ‫̜ͥ́ף‬ȆCDM ͉Ȃౙ֚৖͉̩ۛ́̈́ໝࣣഎ৖͈ۛςΑ·έ͹·ΗȜͅಕ࿒̧̳͓
Ȇಎ؇ଽຸ͈࿨‫͉ڬ‬Ȃૂ༭ͼϋέρΑΠρ·ΙλȜ͈ࢹಃ‫ܖ‬๕ା๵͂஠ఘഎͼϋΓϋΞͻή͈୭̜ࠗ́ͥ
ȆδρϋΞͻͺழ૕ͬ‫͚܄‬΋ηνΣΞͻ͈ႁ̦ࠑ௽എ̈́মުജ‫خͬٳ‬ෝ̳ͥͅȆఉ૖ਅ‫ފ‬൱͈ΙȜθ‫ڰ‬൲̦ਹါ̜́ͥ
Ȇ‫߸۾‬৪̦‫ڎ‬ίυΈρθͬບ‫ث‬४ચ̧́ͥ‫ܥ‬̦ٛȂਹါ̜́ͥ

McColl M and John Dorland,”Conclusion and Directions for the Future “, in Dorland J
and McColl M, “Emerging approaches to chronic disease management in primary
healthcare”, McGill-Queen's University Press, 2007, pp.171-179.
59

-50-

╙  ▵ ࠼ࠗ࠷60㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊ӱ࣭͈අಭȆ‫ڟ״‬! ΡͼΜ͈૽࢛͉ 8,175 ྔ૽Ȃ࿂ୟ͉ 35.7 ྔ໹༷΅υιȜΠσȪ඾ུ͈ 94ɓȫȂ৘ৗ GDP
2 ಣ 2,480 ‫ؙ‬ξȜυ͈ EU ͈ಎ‫̜࣭̳ͥ́̈́ͬړ‬ȪΟȜΗ̴͉̞ͦ͜ 2010 ාȫȃ1990 ාͅ൐ୌΡͼΜ̦ൡ̯࡛֚ͦ̀हͅঢ̞̽̀ͥȃଽহഎ͉ͅȂໝତ͈ଽൂͥ͢ͅႲၛଽࡀ̦࢐
యͬ߫ͤ༐̧̱̤̀̀ͤȂ֓ၷ༗વଷഽ͈་஗͜ͅఱ̧̈́‫ͬޣג‬ဓ̢̞̀ͥȃӲΰσΑΉͺΏΑΞθȪ೹‫ރ‬ఘଷ़࡙͂಺ో༷৆ȫ͈අಭȪ˝ȫ࢖എ֓ၷ༗ࡏଷഽ͈‫ٽ‬ါ! ΡͼΜ்͉̞̻̩২ٛ༗ࡏଷഽͬࢹಃ̱̹࣭̜́ͤȂ֓ၷ༗વͅ‫࡛̱̀͜۾‬ह́͘২ٛ
༗ࡏ༷৆̀ͅ‫̞̯ͥ̀ͦא׋‬ȃ࢖എ֓ၷ༗ࡏଷഽ͈༗ࡏ৪͉౷֖Ȃ૖֖Ȃ૖ෝ༆ͅ୭ၛ̯
̹࡙ͦܳͬခ̳ͥ৖ພ߄ࡩ̜́ͥȃ̹̺̱Ȃࣞਫ਼ං৪֚̈́̓೰͈ૄ࠯ͬྖ̹̱̹૽͉ͅȂ࢖എ֓ၷ༗ࡏ͈͒‫ح‬ව݅ྩ͉̩̈́Ȃయͩͤͅྦྷ‫֓ۼ‬ၷ༗ࡏͅ‫ح‬ව̧̳̭̦ͥ͂́ͥȃ‫͇ٽ‬
࣭ྦྷ͈ 90ɓ̦࢖എ֓ၷ༗ࡏͅ‫ح‬ව̱Ȃ10%̦ྦྷ‫֓ۼ‬ၷ༗ࡏͅ‫ح‬ව̱̞̀ͥ61ȃ̹͘Ḁ̴͉̜̦̑ͩ́ͥྫ༗ࡏ৪̦ంह̳ͥȃ! ࢖എ֓ၷ༗ࡏଷഽ͉Ȃ1970 ාయࢃ฼͉ͅȂ‫ັݯ‬๯͈௩‫ه̦ح‬ఴ͂̈́ͤȂոြ৽̱͂̀‫ݯ‬ັ๯͈ဲଷͬ࿒എ̱̹͂ତষ͈٨೰̦৘ঔ̧̯̞ͦ̀̀ͥȃ̷़͈̥࡙̈́́͜಺ో͈۷ത
̥ͣࡉ̹ఱ̧̈́٨೰͉Ȃ1992 ා଼ͅၛ̱̹֓ၷ༗ࡏࢹ௮༹ͅ‫̧̿ܖ‬Ȃ‫ح‬ව৪̦৖ພ߄ࡩͬ
ࡔ௱ুဇͅ஖఼̧̠̱̹̭̜́ͥ͂́ͥ͢ͅȃ̭͈٨೰͉Ȃ৖ພ߄ࡩ‫އ͈ۼ‬௔ͬ௯ૺ̳ͥ
࿒എ́൵ව̯̹ͦȃ൳শͅȂ৖ພ߄ࡩ͈‫ح‬ව৪͈ςΑ·ͅ؊̲̀৖ພ߄ࡩ‫़́ۼ‬ଽ಺ା࣐̠ͬςΑ·ࢹ௮಺ାଷഽ̦൵ව̯̹ͦȃςΑ·ࢹ௮಺ା͈ॽழ̷͙͉͈ࢃ͜٨೰̦‫̢ͣح‬̞̦ͦ̀ͥȂ‫ུܖ‬എ̈́იழ͉֋঵̯̞ͦ̀ͥȃ‫ح‬ව৪ͥ͢ͅ৖ພ߄ࡩ͈஖఼͈ুဇ͂ςΑ·ࢹ௮಺ାଷഽ͉ȂΡͼΜ͈࢖എ֓ၷ༗ࡏଷഽͬඅಭ̫̿ͥఱ̧̈́ါள̜́ͥȃ̤̈́Ȃ٨‫ͤ͢ͅڟ‬৖ພ߄ࡩ‫އ͈ۼ‬௔̦௯ૺ̯̹ͦࠫ‫ض‬Ȃ৖ພ߄ࡩ͈ତ͉‫̱ઁࡘͅ௸ݢ‬Ȃ1992 ාͅ
1,223 ̜̹̽৖ພ߄ࡩ͉Ȃ2009 ා͉ͅ 202 ́͘ࡘઁ̱̞̀ͥȃ! ड߃͉́Ȃ2007 ාͅ࢖എ֓ၷ༗ࡏ‫އ‬௔‫଼༹̦اޑ‬ၛ̱Ȃྫ༗ࡏ৪͈͒༗ࡏ‫ح‬ව͈݅ྩັ
̫࣭̈́̓ͥ͢ͅྦྷ‫ٯ‬༗ࡏ͈৘࡛Ȃ৖ພ߄ࡩ‫́ۼ‬։̞̹̈́̽̀༗ࡏၳၚ͈ൡ֚‫ا‬Ȃ৖ພ߄ࡩ‫͈ۼ‬঩߄෻໦͂୕़࡙͈਋̫ව࣐̠ͦͬ֓ၷ‫͈߄ܖ‬஻୭͈̈́̓٨೰̦৘ঔ̯̞ͦ̀ͥȃȪ˞ȫ೹‫ރ‬ఘଷ! ‫ٸ‬ြ֓ၷ͂ພ֭֓ၷ͉Ȃྶ‫ߊͅږ‬໦̯̞ͦ̀ͥȃ࢖എ֓ၷ༗ࡏ̦ഐဥ̯ͦͥ‫ٸ‬ြ֓ၷུ͉୯͉Ȃ2009 ා 6 ࠮ 19 ඾ͅ‫ٳ‬ट̯̹ͦల 10 ٝΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬̤̫ٛͥͅমྩޫȪఅ༗ΐλΩϋ௙ࣣࡄ‫ݪ‬ਫ਼ȫ࣒ͥ͢ͅ‫׵‬ඤယͬࡓͅমྩޫ̀ͅ৹ۙ‫ح‬ຊ͈ષȂठࢹ଼̱̀ै଼̱̞̀ͥȃ̱̹̦̽̀Ȃུ୯ܱͅश̯̞ͦ̀ͥඤယ̞͉̾̀ͅȂ࣒‫׵‬൚শ͈͈́͜
̜ͥȃ࣒‫׵‬ါক̤͍࣒͢‫׵‬঩ၳ͉ȂDM ଽॐ‫ه‬ఴࡄ‫ݪ‬͈ٛ HP<http://www.sj-ri.co.jp/research/healthcare_socials/proceedings_pc/10.html>ͅࠇश̯̞ͦ̀ͥȃ61 ̤̈́Ȃ࢖എ֓ၷ༗ࡏ͈‫ح‬ව৪̫࢜ͅȂ࢖എ֓ၷ༗ࡏ̦΃ΨȜ̱̞̈́ํսͬ༞ੲ̳ͥ໐໦֓ၷ
༗ࡏ͂ࡤ͊ͦͥྦྷ‫֓ۼ‬ၷ༗ࡏ̦̜ͥȃ
60

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༗ࡏ࣐֓̽̀ͩͦͥ͢ͅȃ༗ࡏ̹͉֓̈́ͥ͛ͅͅ౷ߊ͈༗ࡏ֓͂৖ພ߄ࡩ̷̸͈ͦͦయນ
̽̀͢ͅࢹ଼̯ͦͥ෇‫خ‬տ֥͈ٛ෇‫ͬخ‬ංͥຈါ̦̜ͥȃ༗ࡏ͉֓Ȃ๊֚֓͂୺࿝֓ͅ໦
႒̯̞ͦ̀ͥȃ2003 ා଼ͅၛ̱̹֓ၷ༗ࡏ߃య‫༹̀̽͢ͅا‬ΊȜΠ΅ȜΩȜ̱͈͂̀‫ܥ‬ෝͬ‫ܢ‬ఞ̱̀‫ز‬ೳ֓ଷഽ̦൵ව̯̞ͦ̀ͥȃࡔ௱̱͂̀‫ز‬ೳ͈֓તٚેͤ͢ͅȂ୺࿝̹֓͘
͉ພ֭ͬ਋૷̳̞̠ͥ͂ࠐႹ̞͂̈́̽̀ͥȃ! ༗ࡏ͈֓૷ၷ༭ਫ̞͉̾̀ͅȂ‫ڎ‬ਗ͈৖ພ߄ࡩႲࣣٛ͂༗ࡏ֓‫ފ‬͈ٛ͂‫ࠀ͈ۼ‬࿩ͤ͢ͅထॳ௙‫ࠨͬڣ‬೰̱Ȃ༗ࡏ֓ͅచ̱͉̀੄ြࣞαȜΆ̭ͦͬ෻໦̳̞̠ͥ͂ॽழ͙̦৾ͣ
̧̹ͦ̀ȃ̱̥̱Ȃ૷ၷဲଷȂ֓ၷ͈ৗ͈೩‫͈̹̞͇͂ͬ͘ئ‬๡฻̦‫̩ޑ‬Ȃ2007 ා͉ͅထॳଷȪ͂ထॳ͈ํսඤ͈́੄ြࣞͥ͢ͅ༗ࡏ͈֓͒෻໦ȫͬ෱গ̱Ȃ஠࣭֚ၙ͈૷ၷ༭ਫ
͈ౙ‫ͬث‬୭೰̱Ȃ‫ڎ‬ਗ̤̫ͥͅࠀ࿩೿͈ࠫष͉ͅ‫ح‬ව৪͈ခພഽͬ‫ܖ‬੔̱͂̀૷ၷ༭ਫ௙
‫ͥ͛ࠨͤ৾ͬڣ‬૧̹̈́ॽழ͙̦൵ව̯̹ͦȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟! ΡͼΜ̦ࢹ௮‫̹̯ͦا‬হၷίυΈρθȪstrukturierte Behandlungsprogrammeȫ͈͂ྴઠ͈ΟͻΐȜΒζΥΐιϋΠȆίυΈρθȪո‫ئ‬ȂȶDMPȷȫ͂ࡤ͐ȫͬ৖ພ߄ࡩͅ৘ঔ̯
̵̞̠ͥ͂ࠁ́ଷഽ̱͂̀൵ව̱̹͈͉ 2003 ා͈̭̜͂́ͥȃ! DMP ͉Ȃ૽࢛͈ࣞႢ‫ا‬Ȃ֓ၷ๯͈௩‫̥͚́̈́ૺ̦ح‬Ȃྕ଻৖ۛۛ৪͈হၷͬ࢘ၚഎͅ৘
ঔ̱Ȃ֓ၷ͈ৗ͈࢜ષͬ଎ͥ͂͂͜ͅȂ֓ၷ๯௩‫ဲ͈ح‬ଷͬ଎̹ͥ͛ͅ൵ව̯̹ͦȃ̴͘Ȃ̷̸ͦͦͬൡࠗΟȜῌͤ͢‫̩̤̱̀෇ږ‬ȃΡͼΜ͈ࣞႢ‫ا‬ၚ͉Ȃ1990 ාయࢃ฼͉ͅ 16ɓ͈କ੔̤͂̈́̽̀ͤȂոࣛࣞ͜Ⴂ‫ૺ̦ا‬ജ̳ͥ͂ထே̯̞̹ͦ̀ȃ֓ၷ๯ͅ‫͉̱̀۾‬Ȃచྴ࿒ GDP ๤́ࡉ̀ 1990 ාయࢃ฼ͅ 10ɓͅൢో̱Ȃ̷͈ࢃ͜௩‫ͬح‬௽̫ 2000 ා͉ͅ 10.2%Ȃ
2002 ා͉ͅ 10.6%ͅષઌ̱̞̹̀ȃ̷̱̀Ȃྕ଻৖ۛۛ৪͈஠૽࢛ͅచ̳ͥ‫ ͉ࣣڬ‬1990ාయͬ೒̲̀௩‫ͬح‬௽̫̞̹̀Ȫ଎ນ 2-7-1 ४ચȫȃ࿑⴫ 2-7-1 ♧ዩ∛‫ޔ‬㜞ⴊ࿶ߩోੱญߦኻߔࠆഀว㧔%㧕ߩផ⒖
30.0
25.0
20.0

糖尿病
高血圧

15.0
10.0
5.0
0.0
1980

1990

2000

2010

2020

（注）1980 年、1990 年、2000 年は実績値、2010 年および2020 年は見通し。
（出典）Euromonitor International Plc,

World Health Databook 2007/2008 , 2007.

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! DMP ൵ව͈ೄ୪͈ࠀ‫͉͈̹̽̈́͂ܥ‬ȂΡͼΜႲཆ༗࠲જ͈ন࿚‫୺̜ͥ́۾ܥ‬࿝‫ز‬տ֥͈ٛ༭࣬੥̜̹́̽ȃ༭࣬੥͉́Ȃྕ଻৖ۛহၷ઼ً̤̞̀̈́֓ͅၷ೹‫̞࣐̦ͥ̀ͦͩރ‬৘ఠ̦̜༷֚ͥȂً઀Ȃະഐ୨̈́֓ၷ೹‫͜ރ‬ంह̱̞̀ͥ͂ঐഊ̱̹ȃ̹͘Ȃྕ଻৖ۛহၷ
̦‫ܢ଻ݢ‬হၷͅ༊ਹ̱ȂထཡȂςΧΫςΞȜΏοϋ͈৾ழ̦ະ௷̱̞̱̹̀ͥ͂ȃ̯ͣͅȂۛ৪͂‫ز‬௼ͅచ̳ͥૂ༭೹‫ܥ͈֗ޗ͂ރ‬͈ٛະ௷Ȃ֓ၷ‫߸۾‬৪‫͈ۼ‬΋ηνΣΉȜΏοϋະ௷Ȃआ‫̩̿ܖͅݶ‬হၷ̦࣐̞̞̭̦ͩͦ̀̈́͂̈́̓‫ه‬ఴ̱̜̬̹͂̀ͣͦȃ! DMP ͉Ȃ2002 ා̴͘ͅȂ2 ߿ൠෂພȂ඿̦ͭͅᑋ̱̞ۛ̀ͥۛ৪ͅచ̱̀൵ව̯ͦȂ̷͈ࢃȂ2003 ාȂ‫ۍ‬൲ྤ଻૤৖ۛȂ2004 ාȂ1 ߿ൠෂພȂቋ௳Ȃྕ଻໾ण଻෹৖ۛͅਜ਼ষ൵
ව̯̹ͦȃ㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ⃻⁁ߣ᡽╷⺖㗴
ԘDMP ͈අಭ
! ஜ੆͈̤͂ͤ DMP ͉ྕ଻৖ۛȆ୆‫ڰ‬ਠ‫۝‬ພͅᑋ̱̞ۛ̀ͥۛ৪ͬచય̳͂ͥඵষȂ२ষထཡ̱͂̀൵ව̯̹ͦȃ൵වͅष̱͉̀Ȃ֚ষထཡ͈൵ව͜࠿൦చય̹̦͂̈́̽Ȃ૧़̹࡙̦̈́ຈါ̭͂̈́ͥ͂Ȃ༹༷აȆ࢘‫௶ض‬೰ͅ‫ږ̱̀۾‬৘଻̦೩̥̹̹̽͛Ȃ൵ව̦ࡉ௣ͣ
̹̞̠ͦ͂ȃ! DMP ͈අಭ͉Ȃଷഽ࿂͉́ςΑ·ࢹ௮಺ା̞̠͂‫ܡ‬ం͈ଷഽͅழ͙ࣺͦͥ͘ࠁ́ଷഽ‫ا‬̯̹̭ͦ͂ȂίυΈρθ࿂͉́ۛ৪͈ਹછഽ൝ͅ؊̲̹‫ٴ‬௄‫ٽ͈ا‬ැ̦‫̭̹̥̽̈́ͦ͘܄‬͂Ȃ‫ز‬ೳ֓ͬಎ૤̱̹͂κΟσ̜̭́ͥ͂Ȃ͈ 3 ത̜ͥͅȃȪ˝ȫଷഽഎ̈́අಭȽςΑ·ࢹ௮಺ାȽ! DMP ͉ȂςΑ·ࢹ௮಺ା͈ 1 ါள̱͂̀ଷഽ‫̹̯ͦا‬ȃߓఘഎ͉ͅȂ৖ພ߄ࡩ͈‫ح‬ව৪̦ DMP ͅ४‫ح‬ഴ჏̳̭ͥ͂ͤ͢ͅȂςΑ·ࢹ௮಺ାͥ͢ͅ࢐ັ߄̦৖ພ߄ࡩͅ঑‫̯ͥͦݯ‬ॽழ͙̞͂̈́̽̀ͥȃ̭͈࢐ັ߄̦৖ພ߄ࡩͅచ̳ͥ DMP ͬ৘ঔ̳ͥͼϋΓϋΞͻή͂̈́ͥȃ! DMP ͉ȂςΑ·ࢹ௮಺ା̞̠͂৖ພ߄ࡩ‫़͈ۼ‬ଽ಺ା͈ॽழ͙ͅழ͙ࣺ̹̭̥ͦ͂ͣ͘ȂίυΈρθ͈਴඲଻ͅཋ̱̞͂ঐഊ̯̞ͦ̀ͥȃ৖ພ߄ࡩ̦ DMP ͬ৘ঔ̳ͥાࣣȂႲཆ༗ࡏ಩͈෇‫̦خ‬ຈါ͂̈́ͥȃ෇‫ͅخ‬ष̱ȂႲཆ༗ࡏ಩͉́ȂςΑ·ࢹ௮಺ାͬ೰༹͛ͥ႓͂
͈ഐࣣ଻̦ૣऔ̯ͦͥȃ̷͈̹͛ȂίυΈρθͅచ̳ͥ৖ພ߄ࡩ͈वၾ̦൱̧̩̩̈́ͤͅȂඤယ̦ࣁೄ‫̜̦ͥ࢜߹̳ͥا‬ȃȪ˞ȫ‫ٴ‬௄‫ٽ͈ا‬ැ̦̞̭̈́͂! DMP ͉ͅȂ४‫ح‬చય͂̈́ͥۛ৪͈Α·ςȜΣϋΈ͉࣐̦ͩͦͥȂਹછഽ൝ͅ؊̲̹‫ٴ‬௄‫ॽ͉ا‬ழ͙͈̥̈́ͅ‫̞̞̈́̀ͦ͘܄‬ȃȪ˟ȫ‫ز‬ೳ֓ͬಎ૤̱̹͂κΟσ! DMP ͉Ȃ‫ز‬ೳ̦֓ಎ૤എ̈́࿨‫଼̞̯ͥ̀ͦࢹ̠̳̹͢ͅضͬڬ‬ȃDMP ͈஠ఘ௨ͬা̱
̹͈̦͜଎ນ 2-7-2 ̜́ͥȃ४‫ح‬৪͈༡ਬ͉Ȃ‫৽א׋‬ఘ̜́ͥ৖ພ߄ࡩ̦࣐̠ȃ‫ز‬ೳ͉֓Ȃ-53-৖ພ߄ࡩ̥ͣ༭ਫͬං̀ DMP ͈΄ͼΡρͼϋͅ‫ࠑ̹̞̿ܖ‬௽എহၷ࣐̞ͬȂຈါͅ؊̲̀
୺࿝֓Ȃພ͈֭͂Ⴒࠈͬ଎ͥȃ‫ز‬ೳ֓ͬಎ૤̳͂ͥκΟσ̦नဥ̯̹ͦၑဇ̞͉̾̀ͅȂ‫ز‬ೳ֓κΟσ͈ଔૺͬ଎̹̞̳ͤ͂ͥଽຸ͈փ̦̜̹̭࢜̽͂Ȃ‫ز‬ೳ֓ո‫ͅٸ‬ίυΈρθ
͈ഐ୨̈́৘ঔȆ಺ାͬ଎̧̭̦ͥ͂́ͥழ૕Ȃ୺࿝૖̦ઁ̞̈́͂ࣉ̢̹̭ͣͦ͂Ȃ̦̜̬̞̈́̓ͣͦ̀ͥȃ࿑⴫ 2-7-2 DMP ߩో૕௝疾病金庫

-契約の締結
-報酬

病院
専門医

患者の紹介

コーディネーター-参加者の募集-治療-紹介 など家庭医（出典）損保ジャパン総合研究所作成。

患者

専門的治療

! DMP ̤̞̀ͅ‫ز‬ೳ͈֓‫̳̹ض‬࿨‫̞̀̾ͅڬ‬ȂDMP ͈ίυΓᾼ௲̱̀৘႕ͬা̱̹͜
͈̦଎ນ 2-7-3 ̜́ͥȃ࿑⴫ 2-7-3 DMP ߩࡊࡠ࠮ࠬߣኅᐸකߩᓎഀ
㧔࿾඙∔∛㊄ᐶ㧔AOK㧕߇ታᣉߔࠆ 2 ဳ♧ዩ∛ߩ DMP ߩ଀㧕
・２型糖尿病の診断が確定
・患者教育、治療プログラムへの参加の意思・生活習慣の改善により血糖値を自分でコントロールする意思・定期的な家庭医の診察を受ける意思・合併症や併発症の検査を受ける意思・初回診療での家庭医の所見
・薬の服用、生活様式、教育日程など家
庭医と患者の話し合いによる治療計画
・治療目標の設定

２型糖尿病の診断、患者（被保険者）の同意書への署名

DMPへの
被保険者の
（自発的な）
参加
治療計画と
目標の設定

・目標に達しない（血糖値、血圧など）・検査の必要性・外来で対処できない場合の入院

専門医
病院への
紹介

・生活習慣の改善
・投薬治療
・２型糖尿病に関連するリスクへの対処

治療

・家庭医による経過観察と測定値の比較
・新たな症状、入院、緊急治療から治療戦・略の妥当性を家庭医が判断継続的ケアȪ੄ങȫ౷ߊ৖ພ߄ࡩȪAOKȫͥ͢ͅ୰ྶ঩ၳͤ͢అ༗ΐλΩϋ௙ࣣࡄ‫ݪ‬ਫ਼ै଼

-54-

ӲDMP ଼͈‫ه͂ض‬ఴ! DMP ͅഴ჏̱̞̀ͥ‫ح‬ව৪͉Ȃ2007 ාশത́஠ίυΈρθࣣࠗ 400 ྔ૽ոષ͂̈́̽̀
̞ͥȃDMP ൵ව̥ͣତා̦ࠐً̱̤̀ͤȂDMP ͅచ̳ͥଽຸ͈ࡉٜȂࡄ‫ݪ‬৪ͥ͢ͅບ‫ث‬̦া̯̞ͦ̀ͥȃଽຸ̱͉͂̀Ȃ̳͓͈̀ DMP ͬచય̱̹ͅບ‫͉ث‬৘ঔ̱̞̞̱̀̈́͂̈́
̦ͣ͜Ȃ֚໐͈৖ພ߄ࡩ͈ίυΈρθ̤̞̀ͅȂۛ৪͈࠿औΟȜῌ٨஝̦ࡉ̭ͣͦͥ͂Ȃ૤௫อैȂෞࢸण͈̈́̓อછ͈೩‫̞̬̜̱ͥ̀̀͂ض଼̭ͬ͂ͥͦͣࡉ̦ئ‬ȃ̹͘Ȃ൚੝͉൵ව͈͒฽చփࡉ̦‫̹̥֓̽ޑ‬঍̥ͣ͜਋̫ව̜̭ͦͣͦ̾̾ͥ͂Ȃۛ৪‫ض଼֗͜ͅޗ‬̦ࡉ̞̱̞ͣͦ̀ͥ͂̀ͥȃ! ̹͘Ȃఱ‫ݪࡄ͈ڠ‬৪ͥ͢ͅͺϋΉȜΠͅ‫಺̩̿ܖ‬औ͉́Ȃۛ৪ྖ௷ഽȂۛ৪͈৖ພȂহၷͅచ̳ͥփেͅ٨஝̦ࡉ͈ͣͦͥ͂ࠫ‫̦ض‬া̯̞͈̜ͦ̀ͥͥ͜͜ȃ! ίυΈρθ஠ఘ̱͈͂̀ບ‫͉͈̞̞࣐̦̈́̀ͦͩث‬Ȃ‫ٴ‬௄‫̓̈́ا‬చયਬ౬஠ఘ͈́डഐ
‫ͬا‬଎ͥॽழ͙̦ழ͙ࣺ̞̞̭ͦ̀̈́͂͘ͅါ֦̦̜ͥ͂ࣉ̢ͣͦͥȃஜ੆̱̹̠͢ͅȂࣞഽͅଷഽ‫̭̹̯ͥ͂ͦ͢ͅا‬਴඲଻͈ࠧශ͂͂͜ͅȂDMP ͈‫ه‬ఴ̢̞̠͂͢ȃ-55-╙  ▵ 㖧࿖㧔㧝㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆ⢛᥊ӱ࣭͈අಭȆ‫ڟ״‬! ఱ‫࣭ྦྷ܀‬Ȫ‫࣭܀‬ȫ͉Ȃ࿂ୟ 10 ྔ 200 ໹༷΅υιȜΠσȪ඾ུ͈࿩ 4 ໦͈ 1ȫȂ૽࢛ 4,977
ྔ૽Ȫ2010 ාȫ̜́ͥȃͺΐͺ੨࣭͈ಎ͉́Ȃ඾ུͅষ̞́ࣞഽ଼ಿͬ৘࡛̱Ȃ2010 ා͈ྴ࿒ GDP ͉ 1 ಣ 145 ‫ؙ‬ΡσȂ1 ૽൚̹ͤ GDP ͉ 20,759 ΡσȪ2010 ාȫ̞͂̈́̽̀ͥȃӲ࢖ਤ‫מ‬୆Ȃ༗ࡏଷഽȂ֓ၷ೹‫ރ‬Ȃ֓ၷ๯ΟȜΗȪ଎ນ 2-8-1 ४ચȫ༗࠲Ȇ֓ၷ‫͈ڠش‬อో͞୆‫ڰ‬କ੔͈࢜ષȂ‫͈ူו‬ৗȂৗ͈̞ࣞ༗࠲֓ၷ̽̀͢ͅ‫͈࣭܀‬໹޳਍ྵ͜ఱ̧̩‫̞͍ͥ̀װ‬ȃ1960 ා͈໹޳਍ྵ͉Ȃ౳ 51.1 पȂ੫ 53.7 प̜̹͈́̽͜
̦Ȃ2008 ා͉ͅ౳ 74.5 पȂ੫ 81.4 प̹͂̈́̽Ȫ੄ങȇOECD Health Dataȃո‫ئ‬൳̲ȫȃ༷֚Ȃ֓ၷ೹‫͉ޙે͈ރ‬Ȃ૽࢛ 1000 ૽൚̹͈ͤႉ઄֓঍ତ 1.6Ȃႉ઄ۭࢌ૖֥ତ 3.8Ȃႉ઄࿪स঍ତ 0.6 ͂Ȃ̴̞ͦ͜඾ུͤ͢ઁ̞̈́ȃ༗࠲֓ၷ͈͒঑੄̞͉̾̀ͅȂ௙‫ ڣ‬53,873
ຐྔΡσ́Ȃ඾ུ͈͕͖ 4 ໦͈ 1 ̜́ͥȪࣔฃ‫಺ث‬ାȪPPPȫༀΡσນাȫȃ࿑⴫ 2-8-1 ଻ஜක≮࠺࡯࠲㧔2008 ᐕ㧕㩷ੱญ㩷 㩷ᐔဋኼ๮䋨ᅚ䋩㩷 㩷ᐔဋኼ๮䋨↵䋩㩷 㩷࿖ౝ✚↢↥䋨㪞㪛㪧䋩㩷 㩷⥃ᐥකᏧᢙ㩷
⥃ᐥ⋴⼔⡯ຬᢙ㩷 㩷⥃ᐥ⮎೷Ꮷᢙ㩷 㩷✚∛ᐥᢙ㩷 㩷ᕆᕈᦼ∛ᐥᢙ㩷 㩷ᘟᕈᦼ∛ᐥᢙ䋨♖␹∛ᐥ╬䉕฽䉃䋩㩷 㩷✚଻ஜක≮ᡰ಴㩷✚଻ஜක≮ᡰ಴㩷୘೎⊛ක≮ᡰ಴㩷✚ක≮ᡰ಴㩷 㩷౉㒮ᡰ಴㩷౉㒮ᄖᡰ಴㩷
ක≮⽷ᡰ಴㩷 㩷㩷 㩷 㩷 Ȫ੄ങȫOECD Health Dataන૏㩷㪈㪇㪇㪇 ੱ㩷ᐕ㩷ᐕ㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆㪈㪇㪇㪇 ੱ㩷㪆㪈㪇㪇㪇 ੱ㩷㪆㪈㪇㪇㪇 ੱ㩷㪆㪈㪇㪇㪇 ੱ㩷㪆㪈㪇㪇㪇 ੱ㩷㪆㪈㪇㪇㪇 ੱ㩷⊖ਁ 㪬㪪㩻㪃㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㪆ੱ㪃㩷㪬㪪㩻㩷㪧㪧㪧㩷㖧࿖㩷㪋㪏㪃㪇㪊㪐㩷㪏㪈㪅㪋㩷㪎㪋㪅㪌㩷㪉㪇㪃㪋㪉㪐㩷
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‫͈࣭֓܀‬ၷ༗ࡏ͉Ȃ඾ུ͂൳အͅ২ٛ༗ࡏଷഽͬ‫ུ̦̞̱ͥ̀͂ܖ‬Ȃ̦࣭͈ͩ༗ࡏ̦‫ح‬ව৪͈޲ྩ୶ͤ͢ͅ໦̥̞͈ͦ̀ͥͅచ̱Ȃ‫͉࣭́܀‬Ȃ2000 ා 7 ࠮ͅ஠࣭ൡ͈֚༗ࡏ৪͂
̹̈́̽ȃႤঃഎͅ‫͈࣭܀‬༗ࡏଷഽͬࡉͥ͂Ȃ1976 ා 12 ࠮ͅ࠲ࢫ༗ࡏ༹ȪHealth Insurance Actȫ͈஠࿂٨ୃͤ͢ͅȂ1977 ා 7 ࠮ոࣛȂਲު֥ 500 ૽಼͈̳͓͈̀ٛ২͉Ȃ࠲ࢫ༗ࡏͬ೹‫̳ރ‬̠ͥ݅͢ྩັ̫̹ͣͦȃ̷͈ࢃȂ༗ࡏ͈౜༗ํս͉ু‫ުא‬৪ͅࢩ̬̹̭ͣͦ͂́Ȃ1989 ා

-56-ͅ‫ٯ‬༗ࡏ̦ో଼̯̹ͦȃ1997 ාȂ࣭ྦྷ࠲ࢫ༗ࡏ༹ȪNational Health Insurance Actȫ̦ଷ೰̯̹̭ͦ͂̽̀͢ͅȂ227 ͈ু‫ުא‬৪࠲ࢫ༗ࡏ౬ఘ͂࢖ྩ֥Ȇজၛ‫ࢷڠ‬ਲު֥࠲ࢫ༗ࡏழࣣ̦
ൡࣣ̯ͦ̀Ȃ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ȪNational Health Insurance Corporation; NHICȫ̦஻୭̯ͦȂ
2000 ා 7 ࠮ͅȂ̳͓͈̀࠲ࢫ༗ࡏ‫א׋‬ଷഽ̦ൡࣣ̯̹ͦȃ̯ͣͅ 2008 ා 7 ࠮͉ͅಿ‫ܢ‬ၷူ༗ࡏȪٚࢌ༗ࡏȫ̦൵ව̯̞ͦ̀ͥȃ֓ၷ༗ࡏ৪͈ൡฺࣣ̞ͅȂ2000 ා 7 ࠮ 1 ඾ͅȂ࠲ࢫ༗ࡏठૣऔ಩ȪHealth Insurance Review
Agency; HIRAȫ̦஻୭̯̹ͦȃ࠲ࢫ༗ࡏठૣऔ಩͉Ȃ༗ࡏ৪Ȃ΍ȜΫΑ೹‫ުރ‬৪Ȃ̤͍͢ఈ͈‫߸۾‬൚ম৪̦֚୨‫۾‬ဓ̳̭̩ͥ͂̈́Ȃ֓ၷ༭ਫ͈ठૣऔ࣐̞ͬȂ༗࠲֓ၷ͈৘ୡͬບ
‫ܥ̳ͥث‬ෝͬခ̱̞̀ͥȃӳ֓ၷ೹‫ރ‬৪͂࠲ࢫ௩ૺȆ‫ۯ‬ၑͅ‫ͥ۾‬૖ਅȪAȫ૽എ঩࡙
༗࠲‫۾‬Ⴒ͈૖֥ͅచ̳ͥ঩‫ັ͈ڒ‬ဓ͉Ȃ༹ၙ́ࡕ‫ܰͅڒ‬೰̯̞ͦ̀ͥȃଽຸ͈྾‫ͬݺ‬঵̾৪͈͙̦Ȃহၷ͞࢖‫מވ‬୆΍ȜΫΑͬ೹‫̧ͥ́ރ‬ȃ֓ၷ༹͉Ȃ༗࠲໛ছ໐̦Ȃ֓঍Ȃভ‫֓ش‬Ȃ‫༷֓܀‬Ȃ੩ॲິ̤͍ۭ͢ࢌ঍ͅ྾‫ͬݺ‬ဓ̢ͥ͂ܰ೰̱̞̀ͥȃ൳༹͉Ȃ༞੩ۭࢌ঍ȂૻআȂ‫ݨ‬আȂ̤͍͢ζΛ΍Ȝΐ঍ͬ੔֓ၷ૽͂ܰ೰̱̞̀ͥȃ̹͘Ȃ̞ͩͥ͠ୌဢ֓ၷ͈
͕̥ͅ‫୺༷܀‬࿝֓Ȃ‫༷܀‬࿪स঍ଷഽ̜ͥ͜ȃ֓঍͉Ȃ৖ພ͈ထཡ͂૷౯Ȃহၷͅ‫ڠ̳֓ͥ۾‬എ̈́ੜ౾̳͈ͬͥ́͜Ȃ6 ා୆͈֓‫ڠ‬໐ͬ௾ު̱Ȃ࣭‫ز‬দࡑࣣͅ‫̳ͥڒ‬ຈါ̦̜ͥȃۭࢌ঍͉Ȃۛ৪Ȃළॲິ͈ၷူષ͈ۭࢌ̤͍͢
૷ၷ͈༞੩Ȃ༗࠲‫ڰ‬൲ͅਲম̳͈̜ͥ́ͤ͜Ȃ3 ාଷ̹͉͘ 4 ා୆͈ఱ‫ͬڠ‬௾ު̱Ȃ࣭‫ز‬দࡑࣣͅ‫̳ͥڒ‬ຈါ̦̜ͥȃ༗࠲঍͉֓ၷ༹ષ͈໦႒͉̩̈́ͅȂ༗࠲ਫ਼ͅ޲ྩ̳ۭͥࢌ঍̦
౷֖২̤̫ۭٛͥͅࢌ͈‫ڰ‬൲࣐̠̭ͬ͂́༗࠲঍̱͈͂̀‫ܥ‬ෝͬ‫̞̱̹ͥ̀ض‬ȃȪBȫ֓ၷ‫۾ܥ‬֓ၷ‫͉۾ܥ‬Ȃ֓ၷ୺࿝‫̦ز‬Ȃহၷͬঔ̱Ȃළິ͈੄ॲͅ੩ႁ̳ͥાਫ਼̜́ͥȃ֓ၷ‫۾ܥ‬͉Ȃ௙ࣣພ֭Ȃພ֭Ȃ૷ၷਫ਼Ȃভ‫ش‬ພ֭Ȇ૷ၷਫ਼(֭֓)Ȃ‫༷֓܀‬ພ֭Ȇ૷ၷਫ਼Ȃၷူਫ਼Ȃ੩ॲਫ਼ͅ໦႒̯ͦͥȃ̹͘Ȃ༗࠲ਫ਼൝͈࢖ਤ‫מ‬୆ΓϋΗȜ֓͜ၷ‫̜ͤ́۾ܥ‬Ȃ֓ၷ΍ȜΫΑ̦೹‫̞̯ͥ̀ͦރ‬ȃ̭͈ͦͣ࢖ਤ‫מ‬୆ΓϋΗȜ͉Ȃ౷ߊౙպͅ୭౾̯̤ͦ̀ͤȂ༗࠲ਫ਼ȪHealth CenterȫȂ༗࠲঑ਫ਼Ȫhealth sub-centerȫȂPHPȪPrimary healthcare postȫ͈ 3̦̜̾ͥȃ༗࠲ਫ਼͉ȂুহఘȪဌ࿂൸Ȫঌ಴ఆȫȫྀͅ 1 ̥ਫ਼୭౾̯̞ͦ̀ͥ֓ၷ‫́۾ܥ‬Ȃ֓঍Ȃۭࢌ঍Ȃ࿪स঍Ȃ‫ူו‬আ͈͕̥Ȃ༗࠲‫֗ޗ‬আȪ‫࣭܀‬༗࠲‫֗ޗ‬Ȇ࠲ࢫ௩ૺ‫ڠ‬ٛͥ͢ͅྦྷ‫ۼ‬঩‫ڒ‬ȫ̦෻౾̯ͦȂ֓ၷ೹‫͂ރ‬୆‫ۯࢫ࠲پ‬ၑȪ૧୆঱Ȇ඿঱Ȃ঱ൺȂ଼ාȆீාȂჇ૽̈́̓ȫ͂౷֖͈́ࢩ༭Ȃ‫಺ڠע‬औ̦࣐ͩͦͥȃ࠲ࢫ௩ૺȆᑋۛထཡ͉‫ٸ‬໐տు̦෇̦͛ͣͦͥȂ‫ٸ‬໐տు̳̥̠̥͉ͬͥ̓‫ুڎ‬হఘඊু͈वၾ̦෇͛ͣͦͥȃ࠲ࢫ௩ૺȆᑋۛထཡ͈̹͈͛
ထॳ͉ȶ̹̭͊୕ȷȪ࣭ྦྷ࠲ࢫ௩ૺ༹͈͂́͜ 1995 ාଷ೰ȫ̦ਰ̀ͣͦȂྀා଼͈‫ͅض‬؊̲̀෻໦‫ͅڣ‬ओ̦̩̾ȃ-57-

༗࠲঑ਫ਼͉Ȃ֓঍Ȫ৽ͅ໶࿨యͩͤͅ޲͛ͥ৹̞֓঍ȫۭ͂ࢌ঍̦෻౾̯ͦȂ෠‫ݽ‬ఆ౷֖ͅ୭౾̯̤ͦ̀ͤȂ̷̯͈ͣͅ‫ͅئ‬Ȃۭࢌ঍͈͙̦෻౾̯̞ͦ̀ͥ PHP ̦̜ͥȃӴ࣭͈‫۾ܥ‬࠲ࢫ௩ૺͅ‫͉̱̀͂۾ܥͥ۾‬Ȃ‫̫̤࣭ͥͅ܀‬஠࣭ൡ͈֚༗ࡏ৪̜́ͥ࠲ࢫ༗ࡏ࢖౬̦̜
ͥȃ࠲૷͈৘ঔ͂࠲૷ΟȜΗ̤͍͢τΓίΠΟȜΗͬ༗ခ̱̤̀ͤȂম႕‫ۯ‬ၑ͈৘ঔ৪́
̜̦ͥȂ࠲ࢫ௩ૺ͉࣐̞ͩ̈́ȃఈͅȂ࠲ࢫଽॐ஠ఘ͈ບ‫ܖ͂ث‬ய֓‫࣭̠࣐ͬݪࡄڠ‬ၛ༗࠲֭ȪNational Institute of HealthȫȂ࠲ࢫଽॐ஠ఘ͈ບ‫ܖ͂ث‬ய֓‫࣭̠࣐ͬݪࡄڠ‬ၛ‫࣭܀‬༗࠲২ٛࡄ‫֭ݪ‬ȪInstitute of Health and Social Welfareȫ̦̜ͥȃӵ࠲ࢫ௩ૺ͂୆‫ڰ‬ਠ‫۝‬ພ‫ۯ‬ၑঐ൵֚ষထཡȪ࠲ࢫ௩ૺȂ࠲ࢫ‫֗ޗ‬ȫ͉Ȃ༗࠲ਫ਼൝̦ਫ਼‫̤̱ͤ̀ۯ‬Ȃਯྦྷ͈ௗ࢛໅౜͉̞̈́ȃ̹̺̱৽ͅຫࣾ৪̦చય̤͂̈́̽̀ͤȂ๱ຫࣾ৪͉༗࠲ਫ਼൝ո‫ু̥ͣٸ‬ဇ̈́ίρΰ΍ȜΫΑͬ਋̫ͥȃඵষထཡȪ࠲૷ȫ͉Ȃ࠲ࢫ༗ࡏ࢖౬̦ਫ਼‫̤̱ͤ̀ۯ‬Ȃ஠ਯྦྷ̦చય́Ȃਯྦྷ͈๯ဥ໅౜͉̞̈́ȃ࡛हȂȶU-Healthȷࢹேͤ͢ͅȂ஠࣭̭̓́͜ΟȜΗ͈වႁȆ‫ר‬။Ȫࡀࡠ୭೰̜ͤȫْ̧̦̦̈́̓́ͥࠗૺ࣐ಎ̜́ͤȃ࠲૷ȂτΓίΠ͈ΟȜΗ;΀ͺΧ;Α̦ࢹಃ̯̞ͦ̀ͥȃ२ষထཡȪਹછ‫ا‬ཡগȂςΧȫ̞͉̾̀ͅȂ֓ၷ‫͈۾ܥ‬ୣහ́೹‫̯ͦރ‬̦ͥȂ૷ၷ༭ਫષ͈୭೰͉̯̞̞̈́ͦ̀̈́ȃ㧔㧞㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ᡽╷ߦ㑐ߔࠆᴪ㕟ӱႤঃഎࠐ֌
‫͉࣭́܀‬Ȃ৖ພ‫ۯ‬ၑ͉̩́̈́Ȃȶম႕‫ۯ‬ၑȷ̱͂̀࠲ࢫ௩ૺ΍ȜΫΑ̦೹‫̞̯ͥ̀ͦރ‬ȃম႕‫ۯ‬ၑ൵ව͈ࠐ֌ͬ۰ౙͅାၑ̳ͥ͂Ȃ͉͂͂͜͜Ȃ֓ၷ๯௩‫̦ح‬෸ࠊ̜̹̽ͅത͉Ȃఉ̩͈࣭͈৖ພ‫ۯ‬ၑ൵ව͂႒য̱̹ે‫̢̞̹̜̦ͥ͂̽ޙ‬ȃߓఘഎ͉ͅȂ2000 ා͈‫ޑ‬ଷ֓࿪໦ުͤ͢ͅ࿩ 16 ಣ 5000 ‫΁;ؙ‬ϋ͈֓ၷ๯௩‫ح‬Ȫ໦ުஜͅ๤͓ 34%௩ȫ̦̜ͤȂ֓ၷ๯చॐ̦ਹါণ̯̭̦̜̹ͦͥ͂̽ȃ̭̠̱̹֓ၷ๯௩‫͈ح‬࿚ఴͅ‫̢ح‬Ȃྕ଻৖ۛۛ৪͈௩
‫̜̦ͤح‬Ȃඅͅྕ଻৖͈ࣣۛ໵છȆ՛‫ͥ͢ͅا‬ව͈֭̈́̓ະഐ୨̈́֓ၷ၌ဥȂ̯ͣͅȂًఉ਋૷Ȃًઁ਋૷͈̈́̓֓‫ڠ‬എͅ๱ࣣၑഎ̈́਋૷࣐൲̦֓ၷ๯௩‫͈ح‬ါ֦̱͂̀ͤ͢ਹণ
̧̳͓͂ࣉ̢̹ͣͦȃ̭̠̱̹࿚ఴͅచ؊̳̹͈ͥ͛֓ၷ๯΋ϋΠυȜσॐ̱͉͂̀Ȃۛ৪ࣣͬၑഎ̈́਋૷࣐
൲ͅ൵̩̭̦͂ਹါ͂ࣉ̢Ȃ‫࣭ڎ‬ଷഽ͈಺औ̥ͣম႕‫ۯ‬ၑ̦൵ව̯̹ͦȃߓఘഎ͉ͅȂ2002
ා 4 ࠮ 10 ඾ ༗࠲໛ছ໐࣭ྦྷ࠲ࢫ௩ૺ௙ࣣచॐȶ࠲༗‫ح‬ව৪͈ࣣၑഎ֓ၷ၌ဥည൵মުȷ
̤̞̀ͅༀ࣭Ȃ΃΢ΘȂ΂ȜΑΠρςͺ͈ম႕̦಺औ̯ͦȂ̷͈ࢃȂఱ‫ڠ‬Ȇࡄ‫ݪ‬৪ͥ͢ͅ‫͈࣭́܀‬ম႕‫ۯ‬ၑίυΈρθ͈‫ٳ‬อȆ౜൚৪‫̓̈́֗ޗ‬Ȃ൵ව੔๵ͬࠐ̀Ȃ2002 ා࣭ͅྦྷ࠲
ࢫ༗ࡏ࢖౬ͥ͢ͅম႕‫ۯ‬ၑκΟσমު̦‫ٳ‬ই̯̹ͦȃ̷͈ࢃȂ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬̦஠࣭ 15঑໐ͅ࠲ࢫ‫ۯ‬ၑআ 31 ྴȪۭࢌ঍ခ঩‫ڒ‬৪ȫͬ෻౾Ȫ 2002 ා 8 ࠮ȡ2003 ා 12 ࠮ȫ̱Ȃུ‫ڒ‬৘ঔͅঢ̞̽̀ͥȃ̷͈ࢃȂ2004 ාͅ 104 ঑໐ͅম႕‫ۯ‬ၑ౜൚৪Ȫ๊֚૖֥ȫ139 ྴ෻-58-౾Ȃ2005 ා 165 ঑໐ͅ‫ڐ‬ఱ̱̞̀ͥȃӲম႕‫ۯ‬ၑ͈‫ٽ‬ැ‫͈࣭܀‬ম႕‫ۯ‬ၑ͉Ȃȶచય৪঑‫͈̹͈͛׳‬༫‫گ‬എͺίυȜΊ̜ͤȂࡢ૽͈ΣȜΒͬ༫‫گ‬എͅྖ̵̹̠̳֚ͥͥ͢ͅႲ͈‫ڰ‬൲̜́ͤȂೄ୪എ̈́΍ȜΫΑ೹‫̩͉̈́́ރ‬Ȃࡢ૽͈ΣȜΒͬບ‫̱ث‬Ȃঀဥ‫خ‬ෝ̈́঩࡙͈ํսඤ́ΣȜΒͬྖ̵̹̠ͥ͢‫ܥ‬ෝႲࠈ̳̭ͥ͂ȷ͂೰݅
̯̤ͦ̀ͤȂ֓ၷ΍ȜΫΑ͈ৗ͈࢜ષ͂֓ၷͅ‫ͥͩ۾‬΋ΑΠ‫ۯ‬ၑȪ๯ဥ/࢘‫̞͈ࣞض‬΍ȜΫΑ͈೹‫ރ‬ȫͬ࿒ঐ̳̯̞͂ͦ̀ͥȃ‫͈࣭܀‬ম႕‫ۯ‬ၑ൵වͅष̱͉̀Ȃ‫͈࣭ڎ‬΍ȜΫΑ‫ۯ‬ၑȂ৖ພ‫ۯ‬ၑȂ֓ၷ၌ဥ‫ۯ‬ၑ͈̈́̓಺औ࣐̞ͬȂ̷͈ࠫ‫̱̀͂ض‬Ȃম႕‫ۯ‬ၑ͈൵වͅ൩͙୨̽
̹ȃম႕‫ۯ‬ၑͬၑٜ̳̹ͥ͛ͅȂ̷͈ͦͣ‫ٽ‬ැ̞̾̀͜ͅ଎ນ 2-8-2 ̹͂͛͘ͅȃ࿑⴫ 2-8-2 ੐଀▤ℂߣ㘃ૃߩ᭎ᔨ
੐଀▤ℂ䋨㪺㪸㫊㪼㩷㫄㪸㫅㪸㪾㪼㫄㪼㫅㫋䋩㩷৻ㅪ䈱ᵴേ䉕ㅢ䈛䇮⾗Ḯ䉕ੂ↪䈚䈢䉍ᦨ⦟䈱⚿ᨐ䈏ᓧ䉌䉏䈭䈎䈦䈢䉍䇮ᦨ⦟䈱䉰䊷䊎䉴⺞ᢛ䈏ⴕ䉒䉏䈭䈇ᕟ䉏䈱䈅䉎ᖚ⠪䈱䊆䊷䉵䉕⏕⹺䈚䇮䉋䉍ㅴ䉖䈣⸘↹䈍䉋䈶⺞ᢛ䉇䉰䊷䊎䉴ឭଏ䉕ㅢ䈛䉝䊒䊨䊷䉼䈜䉎䉅䈱䈪䈅䉎䇯⋥ធ⊛䈭䉰䊷䊎䉴ឭଏ⠪䈪䈲䈭䈇䈏䇮⋙〈䉕䈜䉎 㪈 ੱ䈱ኾ㐷ኅ䈮ᮭ㒢䉕ਈ䈋੐଀▤ℂᵴേో⥸䈱⽿છ䉕⽶䉒䈞䉎䇯੐଀▤ℂ䈲ખⵙ䈱䈵䈫䈧䈱ⷐ⚛䈪䇮ઁ䈱⥃ᐥ⊛ખⵙ䋨଀䈋䈳䇮⥃ᐥ⸻≮ᜰ㊎䉁䈢䈲ᖚ⠪䈱ഥ⸒⠪䋩䉕઻䈦䈩ឭଏ䈜䉎䈖䈫䈏䈪䈐䇮䉁䈢䈲∔∛▤ℂ
䋨㪻㫀㫊㪼㪸㫊㪼㪄㫄㪸㫅㪸㪾㪼㫄㪼㫅㫋䋩䈱৻ㇱಽ䈮䈭䉍ᓧ䉎䋨㪬㪅㪪㩷㪛㪟㪟㪪㩷㩽㪚㪛㪚㩷㪉㪇㪇㪈䋩䇯㩷㩷䉰䊷䊎䉴▤ℂ䋨㫊㪼㫉㫍㫀㪺㪼㩷㫄㪸㫅㪸㪾㪼㫄㪼㫅㫋䋩㩷㪈㪐㪎㪇 ᐕઍ䉝䊜䊥䉦䈱䊕䊮䉲䊦䊋䊆䉝Ꮊ䈪࿾ၞ䈱㜞㦂⠪⑔␩ᜂᒰᯏ㑐䉕ਛᔃ䈮䇮㜞㦂⠪䈫䈠䈱ኅᣖ䈮ឭଏ䈜䉎✚䈩䈱䉰䊷䊎䉴䉕ㅪ❬䊶⺞ᢛ䈜䉎䊒䊨䉳䉢䉪䊃䈪૶䉒䉏䈢↪⺆䈪䇮㜞㦂⠪䈮ឭଏ䈘䉏䉎᭽䇱䈭⒳㘃䈱䉰䊷䊎䉴ో૕䉕ᵴ↪䈪䈐䉎䉋䈉䈮ฦ⒳䉰䊷䊎䉴ᯏ㑐㑆䈱⺞ᢛ䉕ᇦ੺䈮ㆡಾ䈭䉰䊷䊎䉴વ㆐䉕଻⸽䈚䈢䉅䈱䈪䇮੐଀▤ℂ䈫䈾䈿หᗧ⺆䇯㩷∔∛▤ℂ䋨㪻㫀㫊㪼㪸㫊㪼㩷㫄㪸㫅㪸㪾㪼㫄㪼㫅㫋㪀㩷଻ஜක≮૕♽䈱᭴ㅧ䊶䊒䊨䉶䉴㕙䇮⾗Ḯ䉇ଏ⛎⠪䈱⍮⼂䇮ᘒᐲ䇮ᒻᘒ䇮ᖚ⠪䉁䈢䈲ኻ⽎䈫䈭䉎ੱญ㓸࿅䈱⍮⼂䇮ᒻᘒ䇮ஜᐽ⚿ᨐ╬䉕✚䈩䉕⠨ᘦ䈚䈢൮᜝⊛䈭᭎ᔨ䇯ᰴ䈱 㪊 䈧䈱ㇱಽ䈎䉌䈭䉎䇯㩷䊶ၮ⋚⍮⼂䋺∔∛䈱⚻ᷣ⊛᭴ㅧ䉕⸘㊂ൻ䈚䇮ኻ⽎⠪䈮ឭଏ䈘䉏䉎䉰䊷䊎䉴ో૕䈮㑐䈜䉎ᜰ㊎䋨䈠䉏䈡䉏䈱䊒䊨䉶䉴䈪䈬䈱䉋䈉䈭⁁ᴫ䈪䇮⺕䈏䇮䈬䈱䉋䈉䈭䉰䊷䊎䉴䉕ឭଏ䈜䉎䈎䈮㑐䈜䉎䋩䉕฽䉃⍮⼂㩷䊶䉰䊷䊎䉴વ㆐૕♽䋺વ⛔⊛䈭․ቯක≮ኾ㐷ኅ䈍䉋䈶ᯏ㑐䈱㑆䈪䊗䊷䉻䊧䉴䈭䉰䊷䊎䉴વ㆐૕♽㩷䊶ᜬ⛯⊛䈭⾰䈱ะ਄䋺ၮ⋚⍮⼂䉇ᜰ㊎䈍䉋䈶䉰䊷䊎䉴વ㆐૕♽䉕㐿⊒䊶ᡷ⦟䈜䉎ᜬ⛯⊛䈭䊒䊨䉶䉴㩷ක≮೑↪䈱▤ℂ䋨㫌㫋㫀㫃㫀㫑㪸㫋㫀㫆㫅㩷㪤㪸㫅㪸㪾㪼㫄㪼㫅㫋䋩㩷㩷ኻ⽎⠪䈱ㆡวᕈ䉕᳿ቯ䈚䇮଻⸽䈘䉏䉎⛎ઃ䉕⸃㉼䈚䈩䇮ක≮ᔅⷐᐲ䈍䉋䈶ㆡಾᕈ䉇ឭଏ䈘䉏䉎଻ஜක≮䉰䊷䊎䉴䈱ലᨐ䉕⹏ଔ䈜䉎䉅䈱䇯ਈ䈋䉌䉏䈢ᦼ㑆ਛ䈮䈖䈱✚䈩䈱ㆊ⒟䈪ᖚ⠪䈱⁁ᘒ䈮ว䈉ㆡಾ䈭଻ஜක≮ឭଏ⠪䈏ㆡಾ䈭Ბ㓏䈪䉰䊷䊎䉴ឭଏ䈏ⴕ䉒䉏䉎䉋䈉଻⸽䈜䉎䈖䈫䈪䈅䉎䇯㩷Ȫ੄ങȫ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ȷȶ࠲ࢫ༗ࡏম႕‫ۯ‬ၑ̤̫ͥͅ૽ऺ‫ٳ‬อ̤͍͢κΣΗςϋΈ༷մͅ‫ݪࡄ̳ͥ۾‬ȷ༭࣬੥৖ພ‫ۯ‬ၑ͉Ȃచય৪͈ςΑ·ͅ؊̲̀చય৪ͬ‫ٴ‬௄‫̱ا‬Ȃࡢ༆എٚව͂ਬ౬ٚව͂ͬழ
̵͙ࣣ̞͈ͩ̀ͥͅచ̱Ȃࡢ༆എٚව͉́Ȃࡢ૽͈࿚ఴͅ‫̀̽״‬ٚව࿒ດͬ୭೰̱̀ুࡨ
‫ۯ‬ၑ͈΍εȜΠ࣐̠ͬത֑̞͂ͅඅಭ̦̜ͥȪ଎ນ 2-8-3 ४ચȫȃ̹̺̱Ȃ‫͈࣭܀‬ম႕‫ۯ‬ၑ͜৖ພ‫ۯ‬ၑ͈‫ٽ‬ැͅ‫̤̞ͤ̀̿ܖ‬Ȃ৘ष͉ͅḀ̑̈́ͤ߃̞ࣉ̢༷̦͙̀͂ͦͥȃ-59-

࿑⴫ 2-8-3 ∔∛▤ℂ㧔㓸࿅߳ߩ੺౉㧕ߣ੐଀▤ℂ
現状分析
健康度・疾病、医療費、ライフスタイル、など
致傷疾病に対する住民・患者の健康度、医療費、ライフスタイル、心理特性、など
集団に対する介入対象・目標設定・Triage

疾病管理

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個別管理

㓸࿅ߦ߅ߌࠆ໧㗴࡮⺖㗴୘ੱߦ߅ߌࠆ໧㗴࡮⺖㗴㓸࿅ߦ߅ߌࠆ⋡ᮡ୘ੱߦ߅ߌࠆ⋡ᮡ㓸࿅ߦ߅ߌࠆ੺౉ᚢ⇛ㆡ↪࡮ታ〣ࠦࡒࡘ࠾ࠤ࡯࡚ࠪࡦᚻᲑ
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ലᨐߩ⹏ଔ࡮ಽᨆ

Ȫ੄ങȫຊ৪ै଼

ષ੆͈̤͂ͤȂম႕‫ۯ‬ၑ͉ȂུြȂࡢ૽ͬచય̱̹͈̜̦͂́ͥ͜Ȃ‫͈࣭܀‬ম႕‫ۯ‬ၑ͉Ȃ૽࢛ਬ౬ͅ಍࿒̱̹ͺίυȜΊ̜ͥȃ̳̻̈́ͩȂ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬͈༗ခ̳ͥΟȜῌͬ͂͜చય৪ͬࣆࣺ̤ͤͭ́ͤȂచય৪̞͉̾̀ͅȂࡢ༆͈࿒ດ̦୭೰̯͈͈ͦͥ͜Ȃٚව͉̜ͥ೾ഽΩΛΉȜΐ‫̤̯ͤ̀ͦا‬Ȃਬ౬എٚව͂ࣉ̢̧̭̦ͥ͂́ͥȃ৘षͅȂ‫࣭܀‬͈ࡢ༆ٚව̞͉̾̀ͅȂచય৖ۛͅඅ‫ۯ̹̱ا‬ၑ‫ܖ‬੔̤͍͢ίυΈρθͬ‫ٳ‬อ̱ഐဥ̳ͥ
̹͛Ȃഥൡഎ̈́ম႕‫ۯ‬ၑͅ๤͓̞̀ࣞ΋ΑΠΩέ΁ȜζϋΑȂহၷ͈֚۹଻͞Ⴒ௽଻ͬ֋
঵Ȃ೹‫̧̦̭̳́͂ͥރ‬Ȃ௖చഎͅႲࠒ̧̳͓঩࡙̦ୖ৻́΍ȜΫΑ೹‫͈۾ܥރ‬४‫̦ح‬ୟޭഎ̞́̈́‫࡛ͤ́͢ئޙે͈࣭܀‬৘എ̈́ͺίυȜΙ̢̞͂ͥ͜ȃ༷֚Ȃ࠲ࢫ௩ૺমު͈֑̞̞͉͂̾̀ͅȂ࠲ࢫ௩ૺ‫ۯ‬ၑমު͈মުచય৪̦࠲ࢫ̈́ਯྦྷ
̜͈́ͥͅచ̱Ȃম႕‫ۯ‬ၑমު̞͉̾̀ͅȂྕ଻ప࣐଻৖̠ۛͬۛ‫ح‬ව৪̱͂̀Ȃྶฒͅߊ໦̱̞̀ͥȃম႕‫ۯ‬ၑমު̤̞̀ͅ‫ح‬ව৪͈‫ۯ‬ၑ̤̞̀ͅ୆‫ڰ‬ਠ‫۝‬٨஝͈̹͈͛ࡢ༆௖
౴͞‫̹̞࣐̦͛ͥ̀ͦͩ֗ޗ‬Ȃ൳͈֚মު͂ࢋٜ̯̭̜̦ͦͥ͂ͥ͜Ȃম႕‫ۯ‬ၑ̤̫ͥͅ
୆‫ڰ‬ਠ‫۝‬٨஝͈࿒എ͉Ȃ࢘‫ض‬എ̈́৖͈ۛ‫ۯ‬ၑ̜́ͤȂ୆‫ڰ‬ਠ‫͈۝‬٨஝͉ম႕‫ۯ‬ၑ͈৽ါ̈́
࿒എ͉̩́̈́ഐୃ֓ၷ͈၌ဥͬ௯̳̹͈͛ັଟഎ਀౲̜́ͥȃ ̹̺̱ȂࣞࠬգȂൠෂȂෞ௾ಎ൝Ȃచય৖̦ۛ൳̲̜̹́ͥ͛Ȃ௖ࡽ͈Ώ΢ΐȜ࢘‫ܢ̦ض‬ఞ̧́Ȃࣽࢃ͉মު͈ൡ෱
ࣣ͈̹͈͛࿀ྟ̈́࠿൦̦‫ͥͦͣ͛ݥ‬ȃ㧔㧟㧕࠺ࠖࠫ࡯࠭ࡑࡀࠫࡔࡦ࠻࡮ࡊࡠࠣ࡜ࡓߩ⃻⁁ߣ᡽╷⺖㗴ӱম႕‫ۯ‬ၑ͈ߓఘഎ༹༷
ȪAȫచય৖ۛȆచય৪͈஖೰

-60-

చય৖͉ۛȂࣞࠬգȂൠෂພȂෞ௾ಎȂ૤ະ஠Ȃ઀঱ቋ௳ͬచયͅΑΗȜΠȪ̴̞ͦ͜‫ٸ‬ြȫ̜́ͥȃ̭͈ͦͣ৖͈ۛ஖೰̜̹͉̽̀ͅȂঘཌࡔ֦ȪࣞࠬգȂൠෂພȂෞ௾ಎȫȂ௙૷ၷ๯ȪࣞࠬգȂൠෂພȂෞ௾ಎȫȂ৖ພ‫ۯ‬ၑ͈ਹါ଻̥̈́̓ͣȂᑋۛၚ͂হၷ๯ဥͅ‫ܖ‬̧̿Ȃ൚੝ 17 ͈৖ພ̦஖೰̯̹ͦȃߓఘഎ͉ͅȂ2001 ා࣭ྦྷ࠲ࢫ‫಺ူו‬औ͈ࠫ‫ض‬Ȃ‫࣭܀‬࣭ྦྷ̦৽̞ۛ̽̀ͥͅ 10 ఱྕ଻৖ۛȂহၷ΋ΑΠͥ͢ͅ৖ພ஖೰͈‫ܖ‬੔͉ 2002 ා‫͈࣭܀‬65 पոષ͈ࣞႢ৪֓ၷ๯͈ષպ 10 պ͈৖̜̹̦ۛ́̽Ȃ̭͈̠̻ͦͣ 3 ͉̾ᑋۛၚ͂হ
ၷ΋ΑΠၰ༷ͅਹໝ̱̹̹͛डਞഎͅ 17 ͈৖ۛͬ஖೰̱̹ȃষͅȂ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬͈ম
႕‫ۯ‬ၑঐ൵տ֥̱͂̀‫ڰ‬൲̱̞̀ͥ༗࠲֓ၷ͈୺࿝‫ ز‬30 ૽ͬచય̱̹͂ਹါഽບ‫ث‬ȪͺϋΉȜΠ಺औȫ̦৘ঔ̯ͦȂࣞࠬգȂൠෂພȂෞ௾ಎȂ૤ະ஠Ȃ઀঱ቋ௳ͅࣆࣺ̹ͤͦ͘ȃ̷͈ࢃȂ1 ා‫͈ۼ‬ΞΑΠমު͈ࠫ‫ض‬Ȃ૤ະ஠͂઀঱ቋ௳͉Ȃ৖ພ͈ૺ்࣐̦̩Ȃຈါ̈́শ‫ܢ‬ͅম႕‫ۯ‬ၑ̦೹‫̹̯ͦٸੰ̧̹̞͛̈́́ރ‬ȃ2008 ාͤ͢Ȃ‫۾‬୯‫׶‬ȂࣞডࠬછȪডৗ։ુછȫ̦೏‫̹̯ͦح‬ȃম႕‫ۯ‬ၑͬຈါ̳͂ͥచય৪͉Ȃຽ༑എ̈́΍ȜΫΑ̱̳͓͈͂̀̀ۛ৪̦చય৪͂̈́ͥ
̫͉̞ͩ́̈́ȃ̹͘Ȃచય৪஖೰‫ܖ‬੔Ȃ‫ٴ‬௄‫̞̞࣐͉̈́̀̽ا‬ȃ࢖౬̦τΓίΠΟȜΗͬဥ̞Ȃ֚ষ஖೰̱Ȃ΍ȜΫΑ၌ဥ̞͈̾̀ͅ൳փ৾ං࣐̠ͬȃచય৪͈஖೰͉Ȃ֓ၷ๯̦ఉ̞̭̺̫̦͂࿚ఴ̜̫͉̩́ͥͩ́̈́Ȃًઁ਋૷͜Ȃ੿ြ͈֓ၷ๯௩̦̾̈́ͥͅ‫خ‬ෝ଻̦̜̭̥ͥ͂ͣȂًઁ֓ၷ၌ဥ৪͜చય͂̈́ͥȃࣞࠬգ͉́Ȃஜාഽͅ৽ພྴ̜̞͉ͥ໗ພྴ̦ȶུఠ଻ࣞࠬգ(I10)ȷ́ව֭ 1 ̹͉ٝ͘‫ٸ‬ြང࿚ 1 ٝոષ૷ၷ๯୏‫ً̜͈ͥݥ‬ఉ֓ၷ၌ဥ৪Ȫࣞࠬգ֓ၷ၌ဥ৪ಎ૷ၷ๯̦ષպ 5%ȫ͈͕̥Ȃո‫ئ‬͈‫ܖ‬੔ͅ‫̧̿ܖ‬࿹୶ਜ਼պັً̫̯̹ͦઁ֓ၷ၌ဥ৪͜చય͂̈́ͥȪ଎ນ 2-8-4 ४ચȫȃ̤̈́Ȃ΍ȜΫΑ೹‫͈ރ‬ͺίυȜΙ̱͂̀Ȃచય৪̦΍ȜΫΑ͈ంहͬ‫̱෇ږ‬Ȃ΍ȜΫΑ೹‫ͬރ‬ါ୏̳ͥࠁఠ͉̩́̈́Ȃ࢖౬͈‫ݥ୏ັݯ‬ȪτΓίΠȫ঩ၳͬ‫ڰ‬ဥ̱̀చય৪֚ͬষ
஖೰̱̹ࢃȂ΍ȜΫΑ೹‫ރ‬৪̦΍ȜΫΑ၌ဥͅ‫̱̀۾‬൳փ̱̥̀ͣ΍ȜΫΑͬ೹‫̳ͥރ‬ΠΛίΘ;ϋ߿̜́ͥȃ࿑⴫ 2-8-4 㜞ⴊ࿶‫♧ޔ‬ዩ∛ߩㆊዋක≮೑↪⠪ߩㆬቯߩ⠨߃ᣇ
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x╙ 㪈 㗅૏㩿㸊㪀㩷 䇮╙ 㪉 㗅૏㩿㸋㪀䇮╙ 㪊 㗅૏㩿㸉㪀㩷 㩷x㪊㪇 ᱦ䌾㪎㪇 ᱦᐕ㦂඙㑆㜞ⴊ࿶ᖚ⠪ఝవ㩷xஜ⸻⚿ᨐ䈪㜞ⴊ࿶䈫್ᢿ䈘䉏䇮ਥ∛ฬ䈏䇸㜞ⴊ࿶㩿㪠㪈㪇䌾㪠㪈㪊㪀䇹䈪ᦨㄭ 㪈 ᐕ㑆ᴦ≮ታ❣䈏䈭䈇䉅䈱㩷x╙ 㪈 㗅૏㩿㸉㪀㩷 䇮╙ 㪉 㗅૏㩿㸌㪀䇮╙ 㪊 㗅૏㩿㸋㪀㩷 㩷x㪊㪇 ᱦ䌾㪎㪇 ᱦᐕ㦂඙㑆♧ዩ∛ᖚ⠪ఝవ㩷xஜ⸻⚿ᨐ䈪㜞ⴊ♧䈫್ᢿ䈘䉏䇮ਥ∛ฬ䈏䇸♧ዩ∛㩿㪜㪈㪇䌾㪜㪈㪋㪀䇹䈪ᦨㄭ 㪈 ᐕ㑆ᴦ≮ታ❣䈏䈭䈇䉅䈱㩷㧔಴ౖ㧕࿖᳃ஜᐽ଻㒾౏࿅‫ޟ‬ஜᐽ଻㒾੐଀▤ℂߦ߅ߌࠆੱ᧚㐿⊒෸߮ࡕ࠾࠲࡝ࡦࠣᣇ᩺ߦ
㑐ߔࠆ⎇ⓥ‫ޠ‬ႎ๔ᦠ-61-ȪBȫ΍ȜΫΑ͈ࢹ଼ါள
చય৪͈ΣȜΒͬྖ̹̳঩࡙̱͂̀Ȃ൚‫ڂ‬৖ພȂࣣ໵છᑋۛထཡȆহၷ̈́̓ͅຈါ̯͂
ͦͥঔ୭Ȃ୺࿝૖ਅȂুহఘȂ‫ز‬௼ȂδρϋΞͻͺȂ̦̜̈́̓ͤȂম႕‫ۯ‬ၑ ౜൚৪Ȫম႕‫ۯ‬ၑআȫ͂๱୺࿝‫͈ز‬४‫̦ح‬අಭ̞͂̈́̽̀ͥȃম႕‫ۯ‬ၑίυΓΑ̱͂̀Ȃӱచય৪͈ഴ჏͂ບ‫ث‬ȇచય৪̥̠̥͈̓‫෇ږ‬ȂӲ࿒ດ୭೰͂΍ȜΫΑْࠗैͤȇచય৪͈ΣȜΒບ‫ث‬Ȃӳ΍ȜΫΑْ͈ࠗ৘ঔȇഐ୨̈́঩࡙၌ဥ͈̹
͈͛‫ܥ‬ෝ໦‫ا‬ȆႲࠈȂӴచય৪͂΍ȜΫΑ೹‫͈ޙેރ‬έ΁υȜͺΛί͂κΣΗςϋΈ͂ठບ‫଼̯ͥͦࢹ̥ͣث‬ȃͤ͢ߓఘഎȪમळȫ̈́ίυΓΑͬ଎ນ 2-8-5 ͅা̱̹ȃ-62-

࿑⴫ 2-8-5 ੐଀▤ℂࡊࡠ࠮ࠬ
事例管理対象者の案内および選定

本部が構築する対象者を選定基準（優先順位）によって選定−案内文の発送→電話………訪問日の約束

要求査定
訪問：対象者との面談を通して健康問題要因を把握（Needs Assessment）

電話
モニタリング

計画の策定

・要求査定の結果を通して問題リストを選定
・実現可能な事例管理計画を策定（目標、遂行活動を計画）〈①訪問→②電話→③訪問→④電話〉

事例管理を仲介（Intervention）
※ 教育、
相談の遂行

①訪問（２週）：要求査定後、選定された問題リストを仲介②電話（４週）：すでに提供された仲介内容の実践具合を把握、再教育など追加の仲介を実施③訪問（７週）：問題リストに対する対象者の自己管理具合を把握、追加資料提供、追加的教育の実施④電話（10週）：問題リストの管理、実践具合の確認※過小医療利用者は２回だけ実施−ただし、対象者の要求、疾病状態などやむをえない場合は仲介回数を２回追加可能

中間終結

評価
（Evaluation）

訪問：改善の効果を測定
１）目標達成具合の評価
２）対象者の呼応度

正常終了

追跡調査
（Follow-up）

１）１次（正常終結後３ヶ月時点）：郵便案内
２）２次（正常終結後６ヶ月時点）：郵便案内、訪問相談
３）３次（正常終結後９ヶ月時点）：電話相談

再登録Ȫ੄ങȫ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ ࠲ࢫ‫ۯ‬ၑ໐ম႕‫ۯ‬ၑ౜൚ষಿ ΅θȆΪοϋζϋঙ͈͒ιȜσͼϋΗΫνȜͬ͂͜ͅै଼
-63-κΣΗςϋΈίυΓᾼ̞͉̾̀Ȃম႕‫ۯ‬ၑমު͈࿒എ͉Ȃ‫ح‬ව৪͈࠲ࢫ௩ૺ͈̹͈͛
৖͈ۛഐ୨̈́ুࡨ‫ۯ‬ၑȪൠෂພȂࣞࠬգȂෞ੄ࠬȫ̤͍͢Ȃ̷ฺ̠ͦͅഐୃକ੔͈֓ၷ΍ȜΫΑ͈၌ဥ͂֓ၷ๯͈୯ࡘ̦࿒ດ̯͂ͦͥȃ̹̺̱Ȃমު͈࿒എో଼͂Ȃমު͈঵௽എ
̈́อജ͈̹͛ͅບ‫͂ث‬κΣΗςϋΈ̦ຈါ̯͂ͦȂౙ̈́ͥ֓‫ڠ‬എȂࠐफഎ࢘‫ض‬ບ‫̫̺́ث‬̩̈́ process-oriented ͈κΣΗςϋΈ࣐ͩͦͥ͜ȃߓఘഎ͉ͅȂո‫༹̦༷̠͈ͣ৾̈́͢ئ‬̞ͦ̀ͥȃx ૺഽ༭࣬੥ȇমުૺഽ༭࣬੥ྀͬ඾೹੄ْ̳̠̱̱̹ͥ̀ࠗ͢ͅ඾೾༷͈̤͂࢜͂ͤ
ͅଛ࣐̯̞̥ͦ̀ͥͬ‫̳ͥ෇ږ‬ȃx ಎ‫ۼ‬อນȇૺً࣐೾଼͈́‫͂ض‬࿚ఴതͬାၑ̱̀࿚ఴതͅచ̳ٜͥࠨॐͬ࿅̳̹॑ͥ
͛ͅ‫߸۾‬৪̦४‫ٳ࢖̳ͥح‬อນٛͬ‫͈̩͜ٳ‬ȃx ࡛ાບ‫ث‬ȇ໦‫ܢ‬༆ͅૺഽ̤͍͢৘ୡ༭࣬੥ષȂະ૦̈́মުͅచ̳࡛ͥાບ‫ͬث‬৘ঔ̱̀(spot check) యմͬ࿅̳͈॑ͥ͜ȃx ͼϋΗȜΥΛΠͬ೒̲̹মުً೾࢖‫ٳ‬ȇমުΑΗȜΠ 6 ώ࠮ոඤͅͼϋΗȜΥΛΠͬ೒̲̹মުଛً࣐೾ͬ࢖‫ࢵ࠮ྀ̱ٳ‬૧̱̀ଟশບ‫͍̤͢ث‬ন࿚ͬ਋̫̠̳͈ͥͥ͢͜ͅȃx ഩდ಺औȇచય৪ͅίυΈρθૺ࣐̤͍͢ྖ௷ഽບ‫ͬث‬৘ঔ̳͈ͥ͜ȃx χȜ·ΏοΛί͈৘ঔȇບ‫ث‬ఱ̹͉ٛ͘মު༭࣬੥ͬ͂͜ͅບ‫ث‬ఱٛ͞ບ‫ث‬χȜ·ΏοΛίͬ৘ঔ̳ͥȃȪCȫম႕‫ۯ‬ၑ͈̹͈͛૽ऺ଼֗
ম႕‫ۯ‬ၑͅ‫͉ऺ૽ͥ۾‬Ȃ΍ȜΫΑ೹‫ࠁ͈ރ‬ఠ̽̀͢ͅ։̦̈́ͥȂ֚೰‫͈ۼܢ‬ႉ઄ࠐࡑ̦
̜ͤȂۭࢌ঍྾‫ͬݺ‬༗ခ̱̞̀ͥ૽Ȫ࠲ࢫ‫ۯ‬ၑআȫۭ͂ࢌ঍̹͉͘২ٛ໛ছআ͈྾‫̹͘ݺ‬͉঩‫ͬڒ‬ခ̳ͥ࢖౬ȪNHIC)͈૖֥Ȫম႕‫ۯ‬ၑ౜൚৪ȫ̦֚੣ͅ४‫̳ͥح‬ȃম႕‫ۯ‬ၑ౜൚৪͉࢖౬͈૽֥͈̥̈́́ম႕‫ۯ‬ၑުྩͅ֊̹̽૽̹̻́Ȃ̭͈ͦͣ૽͈̠
̻‫۾‬Ⴒ྾‫͉̹͘ݺ‬঩‫ڒ‬৪͉ম႕‫ۯ‬ၑ౜൚৪͈̠̻͈࿩ 4ɓ̜́ͥȃࡹဥࠁఠ͉Ȃ࠲ࢫ‫ۯ‬ၑআ͈ાࣣ͉ࠀ࿩૖́ࡹဥȃম႕‫ۯ‬ၑ౜൚৪͉ୃ͈ܰ࢖౬૖֥ȃ̷̸͈ͦͦ࿨‫͂ڬ‬ΠτȜΣϋΈ͈‫ٽ‬ါͬ଎ນ 2-8-6 ͅা̱̹ȃ-64-

࿑⴫ 2-8-6 ੐଀▤ℂߩੱ᧚
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੺䇮଻ஜᢎ⢒䈍䉋䈶⋧⺣ᛛᴺ䇮੐଀▤ℂ䊒䊨䉶䉴㩷⛮⛯ᢎ⢒䋺੐଀▤ℂኻ⽎∔ᖚ䋨㜞ⴊ࿶䇮♧ዩ∛䇮ᘟᕈᔃਇో∝䇮ዊఽ༎ᕷ䇮⣖තਛ䋩೎䈮੐଀▤ℂᣇᴺ䈮㑐䈜䉎ᢎ⢒㩷

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੐଀▤ℂᜂᒰ⠪㩷୘ੱ䈱ஜᐽ䊆䊷䉵䉕൮᜝⊛䈮ᛠី㩷 㩷ኻ⽎⠪䈮ᵴ↪น⢻䈭⾗Ḯ䉕ᛠី䈚䇮ኻ⽎⠪䈮ኻ䈚䈩ᔅⷐ䈭⾗Ḯ䉕ㅪ❬㩷 㩷୘ੱ䈱ஜᐽ䊆䊷䉵䉕ḩ䈢䈞䉎䉋䈉䈮䉰䊷䊎䉴⸘↹䉕䈢䈩䇮䈖䉏䉕ᣉⴕ䈚䇮䊝䊆䉺䊷䇮⹏ଔ㩷 㩷୘ੱ䈱୘೎⊛䈭ஜᐽ䊆䊷䉵䉕⠨ᘦ䈚䈩ᵴ↪น⢻䈭᭽䇱䈭⾗Ḯ䉕⺞ᢛ㩷ኻ⽎⠪䈍䉋䈶⾗Ḯ䈫䈱䉮䊚䊠䊆䉬䊷䉲䊢䊮㩷䉰䊷䊎䉴䈱⾰䈫䉮䉴䊃䊌䊐䉤䊷䊙䊮䉴䉕⹏ଔ㩷 㩷∔∛೎⺖⒟䇮ஜᐽ଻㒾᡽╷䈱⺖㗴䈫ᣇะ䇮੐଀▤ℂ੐ᬺ䈱᭎ⷐ䇮࿾ၞ␠ળ䈱⾗Ḯᵴ↪䈭䈬䉦䊥䉨䊠䊤䊛䋨଀䋩㩷xട౉⠪ᡰេ੐ᬺ䈱᡽╷േะ㩷x㜞ⴊ࿶䉇♧ዩ∛䈱ℂ⸃㩷x㜞ⴊ࿶䈭䉌䈶䈮♧ዩ∛䊆䊷䉵⺞ᩏᣇᴺ㩷
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xㆇേ≮ᴺ䇮⿷䈱▤ℂ䇮㘩੐≮ᴺ䋯䈭䈬㩷੄ങȇ࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ ࠲ࢫ‫ۯ‬ၑ໐ম႕‫ۯ‬ၑ౜൚ষಿ ΅θȆΪοϋζϋঙ͈͒ιȜσͼϋΗΫνȜͬ͂͜ͅै଼

Ӳ඾ུ͈͒াऐ
‫͉࣭́܀‬Ȃম႕‫ۯ‬ၑ͈͂ྴઠͬဥ̞̞̦̀ͥȂచય৪͈஖೰ͅτΓίΠȪ༗ࡏ࢖౬͈͒
୏‫ݥ‬੥ȫͬဥ̞ͥ̈́̓Ȃ̦࣭͈ͩඅ೰࠲૷Ȇ༗࠲ঐ൵͈ॽழ͙͂‫ވ‬೒̳ͥ໐໦͜ࡉͣͦͥȃ̹̺̱Ȃ࠲૷ΟȜΗ͉Ȃ͈̭ࣽ͂ͧ၌ဥ̴̯̤ͦ̀ͣȂτΓίΠͬဥ̞̹ͥ͛Ȃ൚‫ڂ‬৖ພᑋۛ৪ͬచય̱̹͂ਹછ‫ا‬ထཡȪ२ষထཡȫͬచય̱̞͂̀ͥത͉ఱ̧̩։̈́ͥȃ̹͘Ȃ஠࣭ൡ͈֚༗ࡏ৪̜̹́ͥ͛Ȃ΍ȜΫΑ೹‫͉̹̜̀̽ͅރ‬Ȃ঩࡙͈౷֖༊ह͜ࣉ
ၪ̯ͦȂࡢ༆എ̈́ঐ൵ίυΈρθ̦ै଼̯̞̭ͦ̀ͥ͂ȂౙͅȂೄ߃͈֓ၷ๯̺̫ͅ‫۾‬૤ͬ঵͈͉̩̾́̈́Ȃ੿ြ͈֓ၷ๯௩̦̾̈́ͥͅ‫خ‬ෝ଻ً͈̞ࣞઁ਋૷৪͜చય̱̞͂̀ͥ
̭͂Ȃٚව࣐̠ͬ౜൚৪̱͉͂̀Ȃۭࢌ঍̈́̓֓ၷ૖ո‫̱̀֗ޗ͈͈ͬ͜ٸ‬४‫̵̞̯̀ح‬̭͈ͥ͂̈́̓අಭͬࡉ̧̭̦ͥ͂́ͥȃ̹͘Ȃ‫͉࣭́܀‬Ȃ֓ၷͅࡠ̴ͣૂ༭΋ηνΣΉȜΏοϋܿ੅ȪICTȫ͈၌ဥ̦Ȃ̦࣭ͩͅ๤͓ૺ̞̦ͭ́ͥȂম႕‫ۯ‬ၑ̤̞̀͜ͅచય৪ૂ༭
͈ਓਬ͞‫ۯ‬ၑ̤̞̀ͅ ICT ͈၌ဥ̦ίυΈρθͅେࣺ̞ͤͦ̀ͥ͘ത͜අಭ͈̞͌͂̾͂
̢̠͢ȃ

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ུࣂ͉́Ȃત̱̥̹̦ٚ̈́̽Ȃম႕‫ۯ‬ၑ͈࢘‫̞̀̾͜ͅض‬Ȃ୺࿝ধ͈͒อນ̦࣐̞ͩͦ̀ ͥ Ȫ ႕ ̢ ͊ Ȃ So, Ae-Young, Kim, Yun-Mi, Kim, Eun-Young, et al.: Effects ofCommunity-based Case Management Program for Clients with Hypertension. J Korean
Acad Nurs Vol.38 No.6, 712-725 ̈́̓ȫȃ̹̺̱Ȃ̷͈ͦͣა໲ͬࡉͥࡠͤȂౣ‫ܢ‬എȪ฼ා೾ഽȫ̈́࢘‫͈͈ͥͦͣ͛͜෇͉ض‬Ȃ୆‫ۯࡨু̹ͤͩͅپ‬ၑ̦ຈါ͂̈́ͥ୆‫ڰ‬ਠ‫۝‬ພ̞͈̾̀ͅಿ‫ܢ‬എ̈́ٚව࢘‫࠿͈ض‬൦͉਱໦̢͉̞̞͂̈́͂এͩͦͥȃ̹͘Ȃম႕‫ۯ‬ၑͅ‫۾͈ުܑ̳ͥ۾‬ဓ̞͉̾̀ͅȂ༹ၙષ͈ା๵̦ະ਱໦̜̹̭̥́̽͂
ͣȂܑު͈४‫̹̥̞࣐̜͉̽̈́̀ͦͩͤ͘ح‬ȪͼϋΗΫνȜ৘ঔশത͉́Ȃ2009 ාͅ࠲ࢫ௩ૺ̤̫ͥͅ‫ူו‬΍ȜΫΑ୶ૺ‫༹ا‬մ଼̦ၛ̳ͥထ೰̜́ͤȂ൳༹մ଼ၛܑͤ͢ͅު͈४
‫̹̜̭͈̽́͂͂ͥͦͣ͛෇̦ح‬ȫ̦ȂࣽࢃȂܑު̦౷֖ਯྦྷ͈࠲ࢫুࡨ‫ۯ‬ၑ΍εȜΠͅ४‫̳ͥح‬ાࣣ͈຦ৗ‫ۯ‬ၑ̦Ȃ̦࣭͈ͩඅ೰༗࠲ঐ൵͂൳အͅ‫ه‬ఴ͈̈́ͥ͂͜ͅࣉ̢ͣͦͥȃ‫͈࣭֓܀‬ၷ೹‫ॽ͈ރ‬ழ͙͉Ȃ౷֖͈࢖ਤ‫מ‬୆ΓϋΗȜ֓͜ၷͬ೹‫̭̞̱̓̈́͂ͥ̀ރ‬Ȃ̦࣭ͩ͂։̈́ͥത̜͈͈ͥ͜͜Ȃ༗ࡏ৪̦஠࣭ൡ̜̭͉֚́ͥ͂Ȃ࣭ྦྷ͈‫ݳ‬ਯ౷͞૖ા̦
་ͩ̽̀͜Ȃࡢ૽͈༗࠲֓ၷΟȜΗͬ৖ພ‫ۯ‬ၑͅ၌ဥ̳̭̦ͥ͂Ȃ̦࣭ͩͤ͢͜ယօ̜́
ͤȂུࣂ́ત̱̹ٚࡢ༆‫ۯ‬ၑո‫͜ͅٸ‬Ȃအș̈́֓ၷ͈ৗບ‫ͅث‬၌ဥ̯̞ͦ̀ͥȃ̭̠̱̹ΟȜΗ၌ဥ͈̜༷̞ͤ̾̀͜ͅȂࣽࢃȂ̦࣭͈ͩ͒၌ဥ‫خ‬ෝ଻̞̾̀ͅ࠿൦̳ͥ‫ث‬౵̦̜͈ͥ͂͜এͩͦͥȃུ঩ၳ͉ո‫଼͈̹̱́͜ैͤ͢ͅئ‬Ȃड૧͈ે‫͉͂ޙ‬։̭̦̜̈́ͥ͂ͥȃ1.

࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ȶ࠲ࢫ༗ࡏম႕‫ۯ‬ၑ̤̫ͥͅ૽ऺ‫ٳ‬อ̤͍͢κΣΗςϋΈ༷մͅ‫۾‬̳ͥࡄ‫ݪ‬ȷ༭࣬੥Ȫ2005 ා 7 ࠮ๅȫ

2.

࣭ྦྷ࠲ࢫ༗ࡏ࢖౬ ࠲ࢫ‫ۯ‬ၑ໐ম႕‫ۯ‬ၑ౜൚ষಿ ΅θȆΪοϋζϋঙ͈͒ιȜσͼϋΗΫνȜȪ2009.11.2ȫ

3.

ΰσΑζΛ·Α২ͼϋΗΫνȜȪ2009.11.2ȫ

4.

‫װ‬ଲȪπϋΓͼȫఱ‫ڠ‬༗࠲‫ڠش‬ఱ‫֭ڠ‬༗࠲࣐ଽ‫ޗشڠ‬਎ ΢θȆ;ϋ;‫ޗ‬਎͈͒ͼϋΗΫνȜȪ2009.11.3ȫ

5.

ࢺၿȆࡔਗȪ΃ϋΤϋȆ;΁ϋΐνȫ࣭ၛఱ‫ڠࢌۭڠ‬໐ ΕȆ΀πϋ‫ޗ‬਎͈͒ͼϋΗΫνȜȪ2009.11.3ȫ

6.

2006 ා 5 ࠮࡛౷಺औ(࣭ྦྷ࠲ࢫ༗ࡏ࢖౬൝)-66-╙  ┨ ฦ࿖Ყセ߆ࠄᓧࠄࠇࠆ␜ໂ╙  ▵ వㅴฦ࿖ߩ᡽╷ታᣉߩ⺰ὐߣ᡽╷ታⴕߦ㑐ߔࠆ⺖㗴㧔㧝㧕᡽╷ታᣉߩ⺰ὐ
ల 2 ડ͈‫̥ͣޙે͈࣭ڎ‬ȂΟͻΐȜΒζΥΐιϋΠͅ‫̳ͥ۾‬ଽॐͬ৘ঔ̳ͥष͈̓ͅ
̠̈́͢აത̦̜̥ͥͬո‫ͅئ‬ାၑ̱̹ȃӱΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࢘‫͂ض‬պ౾̫̿ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ2000 ාయ੝̷͈͛࢘ͅ‫ض‬Ȃඅͅ΋ΑΠॉࡘ࢘‫̞̀̾ͅض‬ఱ̞ͅ‫ܢ‬ఞ̯̹ͦȃ̱̥̱Ȃ৘બࡄ‫͈ݪ‬໦ଢ଼ࠫ‫̱̀͂ض‬Ȃࠫა͉̺͘
੄̞̞͉̯̞̦̀̈́͂ͦ̀ͥȂ൚੝͈‫ܢ‬ఞ͕͈̓ఱ̧͈͉̞͈̈́́̈́͂͜ࡉ๊ٜ̦֚
എ̞̈́̽̀ͥͅȃༀ࣭͉́Ȃࡹဥ৽Ȇਗଽຸͬ‫͚֓܄‬ၷ༗ࡏ৪̦ΟͻΐȜΒζΥΐι
ϋΠȆίυΈρθͬनဥ̱΋ΑΠॉࡘ࢘‫ض‬Ȃඅͅࠑ௽എ̈́࢘‫ܢͬض‬ఞ̱̹̦৘࡛͉̱
̥̹̈́̽͂ࣉ̢ͣͦͥȃ̱̥̱Ȃࣣၑഎ̈́ίυΈρθ͉ȂςΑ·έ͹·ΗȜ͈ࡘઁ͈̈́̓࢘‫ވ͉̞̭̬̜̀̾͂ͥͬͅض‬೒͈ၑٜ̞̈́̽̀ͥͅȃༀ࣭̤̫ͥͅΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ೒ુ͈֓ၷ༗ࡏͅழ͙ࣺͦͥ͘ດ੔௡๵എ͈̈́̈́͜ͅ
̹̽͂ࣉ̢ͣͦͥȃඅͅȂcare management ͉ΟͻΐȜΒȆζΥΐιϋΠ̱͂̀େͭ
ͅ‫ڰ‬ဥ̯̞ͦ̀ͥȃༀ࣭ո‫࣭ם͈ٸ‬Ȃ΂ȜΑΠρςͺ൝͉́Ȃ࢖എ̈́ଽॐ൚ޫ̦ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈๯ဥ୯ࡘ͉ͅ‫ܢ‬ఞ͉̱̞̦̈́ȂςΑ·έ͹·ΗȜ͈ࡘઁ͈࢘‫̀͛෇ͬض‬൵ව৘ঔͬ௽̫̞̀ͥȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬఱܰ࿅ͅ৘ঔ̱̀࢘‫̠̞̹̜̦͂̽ض‬Ȃ΀ΫΟϋΑȆαȜΑ͈ࠫა͉੄̞̞̦̀̈́Ȃ࢖എ̈́ଽॐ൚ޫ͂̽̀ͅྕ଻৖ۛచॐȆଽॐ̜́ͥ Chronic Disease Management(ո‫ئ‬Ȃུ୯͉́ CDM ̞̠͂)ͬ৘ঔ̳ͥष͈Ȃ͈͌͂̾ခႁ̈́਀౲̞̠͂պ౾̫̞̿̈́̽̀ͥͅȃ! ! Ӳે‫ޙ‬໦ଢ଼෤՜͈̹͈͛κΟσ͂ଽॐ‫ه‬ఴ͈෤՜ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ਀౲̱͂̀၌ဥ̳ͥଽॐͬ࠿൦̳ͥषȂଽॐ৘ঔ͈࠿൦ͅဥ̞ͣͦͥκΟσ͉Ȃల 1 ડ́৾ͤષ̬̹ Wagner ̦ͣ೹੹̱̹Chronic Care Model ̜̭̦́ͥ͂Ȃల 2 ડ́৾ͤષ̬̹࣭ș๊͉֚́എ̜́ͥ(࿔ა̷̸ͦͦ৘ఠͅ؊̲̀ਘୃ̯̞̦ͦ̀ͥȂ੄อത͉ Chronic Care Model ̜́ͥȫȃ૽࢛͈ࣞႢ‫ا‬൝ͤ͢ͅྕ଻৖ۛ࿚ఴ̦ਹါ̹̞̠̈́̽͂ͅ৖ພࢹ௮͈་‫ͅا‬చ̱̀Ȃ࿚ఴٜࠨͬ଎̠̳ͧ͂ͥषͅȂྕ଻৖͈ۛထཡ঑‫ࣣͬ׳‬ၑഎ࢘‫ض‬എͅ৘ঔ̳ͥΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉ခႁ̈́਀౲̦̈́ͥͅȂ̷͈ഐဥ̯ͦͥႀ֖͉ίρͼζςΉͺ͈ႀ֖̜́ͥȃChronic Care Model ͉ȂίρͼζςΉͺ٨‫ه͈ڟ‬ఴȆ༷࢜଻ͬ࠿൦̳͈ͥͅ࿨ၛ๊֚̾͂എͅࣉ̢̞ͣͦ̀ͥȃΊȜΠ΅ȜΩȜଷͬ৘ঔ̱̞̀ͥȂ‫࣭ם‬Ȇ΂ȜΑΠρςͺ͉̲ͬ͛ȂίρͼζςΉͺ͈ႀ֖̦ྶ‫͉࣭́̈́ږ‬Ȃພ֭΍ȜΫΑ̥ͣ community base ͈ίρͼζςΉͺ΍ȜΫΑ͈͒ΏέΠͬ৘ঔ̱̠̱̞͂̀ͥ͢ȃCDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρ-67-θ͈৘ঔ͉ȂίρͼζςΉͺ٨‫̠͈̥͈̓́̈́͢ͅڟ‬ဥ̧̞͓̥͈ͣͦͥ͂აത̦̜ͥȃ! ! ӳଽॐ࿒ດ͈୭೰͂‫߸۾‬ႀ֖ΰσΑΉͺ٨‫ ͉̞̜ͥڟ‬CDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳ͥ࿒
എ̦֓ၷ๯௩‫΃͈ح‬Ȝή͈ဲଷ̥Ȃ࢘ၚ଻Ȇ࢖໹଻͈࢜ષ̥̈́̓̽̀͢͜ͅȂٜࠨ਀౲̱͈͂̀ CDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬဥ༹̞༷̦ͥ་̩ͩ̽̀ͥ
̞̠͂აത̦̜ͥȃఉ̩͈ાࣣȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ͉ȂίρͼζςΉͺ٨‫̱۪͈֚̀͂ڟ‬ၛմ̯ͦଔૺ̯ͦͥȃߓఘഎ͉ͅȂࣞ‫̈́ڣ‬ພ֭঩࡙͈ঀဥॉࡘȂව֭Ȇठව͈֭ࡘઁȂ̤͍͢ව֭‫͈ۼܢ‬ౣੀ̦̈́̓ࣉၪ̯̞ͦ̀ͥȃ̤̈́ȂίρͼζςΉͺ٨‫̦ڟ‬Ȃ‫ݯރ‬ఘଷ͈ఱܰ࿅̈́ழ͙ఢ̢́͘‫͚܄‬౲‫ܡ̥͈͈͜ٴ‬ంఘଷ͈‫ފ‬൱ఘଷ͈‫͈اޑ‬౲‫ͅٴ‬ၣ̥ͥ̽̀͘͢ͅȂ࿚ఴٜࠨ਀౲̱͂̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈̠ͬ̓͢ͅဥ̧̞͓̥̦ͥ་̩̞̠ͩ̽̀ͥ͂აത̜ͥ͜ȃ̹͘Ȃ‫͈࣭ם‬အͅ NHS and Social Care Model ͈̥̈́ͅ CDM ̤͍͢ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦ࣺ৾ͤͦͥ͘‫͉́߸۾‬Ȃ̭͈ͦͣႀ֖͈͂ႲࠫȆ༫‫̓ͬ܄‬̧̠̳͓̥͈͂აത̦੄̩̀ͥȃࣞႢ৪Ήͺ͈ႀ֖͉́Ȃໝତ৖͈ۛ࿚ఴ̠ͬ̓ե̠
̧͓̜̥́ͥ͜აത̈́ͤͅංͥȃ! ! Ӵଽॐജ‫͈ٳ‬৘࢘଻
CDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̳͉ͥͅȂ‫ܡ‬ం͈মުͅ‫̢̀ح‬೏‫़࡙͈ح‬Ȫ̜̞͉ͥఈ͈মު͂యఢ̳ͥȫ͈̈́̓ந౾̦ຈါ̈́ͥͅȃΰσΑΉͺͅ‫̳ͥ۾‬೏‫ږ़͈࡙ح‬༗़̜̞͉࡙͈ͥΏέΠ͉Ȃယօͅଽহഎ࿚ఴ̳̞̈́ͤ͞ͅȃ̷͈փྙ͉́Ȃଽহે‫̦̥͈̠̦̈́̓ޙ‬ਹါ̈́აത͂̈́ͥȃ! ! ! 1 ා 2 ාౙպ͈ౣ‫͉୽ࠨܢ‬ະ‫خ‬ෝ̜́ͤȂಿ‫ܢ‬എ̈́ΗͼθέτȜθͬຈါ̳̹͂ͥ͛Ȃಿ‫ܢ‬എ̈́ജ‫୽ٳ‬ၞ͈̠ͬ̓͢ͅॐ೰̳̥͈ͥ͂აത̦̜ͥȃ΃΢Θ͈΂ϋΗς΂ਗ͈
Logic Model ͉̈́̓Ȃ̷͈‫ه‬ఴ৾ͤͅழ̺ͭȂ͈͌͂̾ࢡ႕̜́ͥȃমު̦ಿ‫ܢ‬എࠑ௽എͅ৘ঔ̯ͦ৘̦̜̦͉࢘ͥͅȂͼϋΓϋΞͻή̦ޭ͛̀ਹါ́
̜ͥȃ႕̢͊Ȃ‫ ̫̤࣭ͥͅם‬GP ͈༭ਫ঑໡Α΅Ȝθ̤̫ͥͅͼϋΓϋΞͻή͈୭̦ࠗ̈́̓Ȃࠑ௽എ̈́‫ڰ‬൲ͬଔૺ̳ͥȃఉ૖ਅ‫ފ‬൱ͬ৘࡛̳ͥ൚ম৪͈ͼϋΓϋΞͻή͈୭ࠗ͜ਹါ̜́ͥȃ࿚ఴે‫͉ޙ‬Ȃ̷͈শ̷͈౷֖́։̈́ͥȃ࿚ఴ͈ఉအ଻͉ٜࠨ༹༷͈ఉအ଻ͬ୆͙੄
̳‫خ‬ෝ଻̦̜ͥȃ̷͈փྙ́Ȃٜࠨॐ̱͈͂̀ CDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ఉအ଻ͬ‫ݺ‬ယ̳̭͉ͥ͂ਹါ̈́აത̈́ͥͅȃOne fits all ͈ͺίυȜΙ͉৘षഎ͉̞́̈́ȃ
CDM ͂ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃ‫ږ‬ၛ̯̹ͦ࿷༹͈༷̦̜͈֚ͥ́
͉̩̈́Ȃ̤̈́อജഷષ̜ͥͅȃ̷͈փྙ́ȂͼΦαȜΏοϋͬညอ௯ૺ̳ͥκιϋΗθོ͈̠ࣺ͚̥͈ͬ̓͛͂͢ͅაത̜ͥ͜ȃ‫̢̀ح‬Ȃ΂ȜΑΠρςͺ͈̠͢ͅȂ৘க-68-౶͈࢐ၠ͈ॽழ͙̩͈̠̿ͤͬ̓͢ͅࠑ௽എ࢘ͅ‫ض‬എͅ৘ঔ̧̥͈́ͥ͂აത̜ͥ͜ȃ㧔㧞㧕᡽╷ታⴕߦ㑐ߔࠆ⺖㗴! ոષ͈აതͬ൩̢̀͘ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐͬ৘࣐
̱̠̳͂ͥ͢ष͈‫ه‬ఴ̱͉͂̀Ȃո‫͈ئ‬ത̧̜̬̭̦ͬͥ͂́ͥȃӱႤঃഎ২ٛഎଽহഎ໲ྤͅ؊̲̹࿚ఴႀ֖͈୭೰Ȃٜࠨॐ͈஖఼
ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐ͉Ȃ̷ͦুఘ̱́ۖࠫඊၛ̱̹ଽॐ́
͉̩̈́Ȃͤ͢ࢩํս̜̞͉ͥಿ‫ܢ‬എ̈́ଽॐ࿒ດͬ৘࡛̳༷ͥॐ̞͂̈́̽̀ͥȃ႕̢͊Ȃ৖ພࢹ௮͈་‫ͅا‬చ؊̳ͥΰσΑΉͺ‫ݯރ‬ΏΑΞθ͈٨‫ڟ‬Ȇ٨ၻ͈֚໐̱͂̀Ȃ̜̞͉ͥίρͼζςΉͺ͈ΏΑΞθ̤̫ͥͅ຦ৗȆ࢘ၚ଻͈٨஝ॐ͈֚໐̱̜͂̀̈́̓́
ͥȃ̳̻̈́ͩȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ̞͈̾̀ͅიழͅ
‫ه̳ͥ۾‬ఴ̦̜ͥȃΟͻΟͻΐȜΒζΥΐιϋΠȆίυΈρθͅ‫̳ͥ۾‬ଽॐ࿒ດ͉ȂႤঃഎ২ٛഎଽহഎ໲ྤͅ؊̲̹࿚ఴႀ֖́ഐ୨ͅ୭೰̱Ȃ৘࣐̳̭̦ͥ͂‫ͦͣ͛ݥ‬ͥȃ! Ӳಿ‫ܢ‬എ̈́঩࡙͈‫ږ‬༗͂୽ၞ! ! ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθͬ৘ঔ̱̀࢘‫͉̦̜̦ͥͅض‬Ȃಿ‫ͬۼܢ‬ါ̳ͥȃ̭͈̹͛Ȃಿ‫ܢ‬എ̈́঩࡙͈‫ږ‬༗̦ຈါ͂̈́ͥȃଽॐ৘ঔͅष̱̀ࡠ़̹࡙ͣͦͬ
ൎව̳ͥषȂ͈̠̓̈́͢࿹୶ਜ਼պ̥̦͂̈́ͥ࿚ఴ̦̈́ͥͅȂଽॐ࿹୶ਜ਼պ͈࿚ఴ͉Ȃౣ‫̩͉̈́́ܢ‬Ȃಿ‫̹ͥͩͅܢ‬ȃಿ‫ܢ‬എ̈́୽ၞͬခ̱̞̥̀ͥȂࠑ௽എͅ୽ၞͬଛ࣐́
̧̥̦ͥ‫ه‬ఴ̜̦́ͥȂ̭͈‫ه‬ఴ͉Ȃଽॐࠁ଼̤̫ͥͅ২ٛഎࣣփ̤͍͢ଽহഎ༷ૻ
͈͂‫̦߸۾‬૬̞࿚ఴ̜́ͥȃӳ‫߸۾‬൚ম৪͈ͼϋΓϋΞͻήΏΑΞθ͈୭ࠗΰσΑΉͺ΍ȜΫΑ೹‫߸۾ރ‬൚ম৪͈ͼϋΓϋΞͻή୭ࠗͅ‫ه̳ͥ۾‬ఴ̦̜ͥȃ‫۾‬߸൚ম৪͂̽̀ͅྫၑ̈́ͼϋΓϋΞͻή͈ॽழ͙̞͂̈́̽̀ͥ͂Ȃࠑ௽എ̞ͤ͢͢ͅ
ଽॐ࢘‫ܢͬض‬ఞ̳̭͉ͥ͂ඳ̱̞ȃΟͻΐȜΒȆζΥΐιϋΠ͉Ȃྕ଻৖ۛͬచય͂
̳̹ͥ͛ಿ‫͈ۼܢ‬মު͈̈́ͥ́ͅȂ̭͈ത͈෻ၪ͉ਹါ̜́ͥȃ̹͘Ȃྫၑ̈́‫ޑ‬ါ̦̩̈́͂͜Ȃഐ୨̈́ͼϋΓϋΞͻήȆ‫׳‬੩ଷഽ́ྕ଻৖ۛͅ‫̳ͥ۾‬৖ພထཡ঑‫ڰ׳‬൲̦‫ܢ‬ఞ̧̠̳́ͥͥ͢ͅຈါ̦̜ͥȃӴ൚ম৪͈ழ૕ෝႁ(capability)! ͼϋΓϋΞͻήΏΑΞθ͈୭̦ࠗഐ୨̜̹̱́̽͂̀͜Ȃ৘࣐̳ͥ൚ম৪̷̦͈ෝ
ႁͬခ̱̞̥̦̀ͥ࿚ఴ͂̈́ͥȃ঑‫׳‬ٚවͬ਋̫ͥࡢ૽͈ͼϋΓϋΞͻή͈࿚ఴ͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈࿚ఴ̜̦́ͥ͜Ȃ঑‫׳‬ٚවͬ৘ঔ̳ͥழ૕௰
͈ழ૕ෝႁ(capability)͉ȂΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈ଽॐ‫ه‬ఴ̱͈͂̀
࿚ఴ̈́ͥͅȃΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͉Ȃࡢ૽̜̞͉ͥਬ౬ͅచ̱̀ழ
૕̦঑‫׳‬ٚව࣐̠ͬȃ႕̢͊Ȃழ૕ඤ̤̫ͥͅఉ૖ਅ͈‫ފ‬൱ͬ৘ঔ̳ͥழ૕ෝႁ̈́̓
ழ૕͂̽̀ͅຈါ̯͂ͦͥழ૕ෝႁ̦ߓ๵̯̠̳̭ͦͥͥ͂͢ͅȂ̷͈̠̈́͢ழ૕̦

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ઁ̞̈́ાࣣ͉ͅူ଼Ȇ࢜ષ̵଼̯‫ࠫͅض‬৘̵̯̭̦ͥ͂‫ه‬ఴ̈́ͥͅȃ! ӵͼΦαȜΏοϋ͈௯ૺ! ! ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̤͍͢ CDM ͉Ȃ̺͘อജഷષ̜ͥͅȃఉအ࡛̈́ા͈৾ழͬ੻႗̱ȂͼΦαȜΏοϋͬညอ௯ૺ̳ͥຈါ̦̜ͥȃ╙  ▵ ᣣᧄߩ․ቯஜ⸻࡮․ቯ଻ஜᜰዉ੐ᬺߩ․ᓽߣ᡽╷⺖㗴㧔㧝㧕ᣣᧄߩ․ቯஜ⸻࡮․ቯ଻ஜᜰዉ੐ᬺߩ․ᓽ
! ӱඵ͈̾ၠͦͬ঵̾ଽॐ
2006 ාͅඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵মު̦৘ঔ̯ͦͥͅঢͥࠐ֌͉ͅȂఱ̧̈́ඵ͈̾ၠ
̦̜ͦͥȃ͉͌͂̾Ȃ2000 ා̥ͣ‫ٳ‬ই̯̹࣭ͦྦྷ࠲ࢫ̩̿ͤ‫׋‬൲ȶ࠲ࢫ඾ུ 21ȷ͈ၠ̜ͦ́ͥȃ
2000 ා̥͉ͣȂ10 ΃ාْ࣭ࠗ́ྦྷ‫׋‬൲̜́ͥȶ࠲ࢫ඾ུ 21ȷ̦‫ٳ‬ই̯ͦȂ2002 ා̷༹͉͈ͅഎ‫ܖ‬๕͈‫ࢫ࠲̹͈͛ͅاޑ‬௩ૺ଼༹̦ၛ࢖ື̯̹ͦȃȶ࠲ࢫ඾ུ 21ȷ͉Ȃঔॐ଼͈‫͈ض‬ບ‫̦ࣾث‬ඳ̜͈́ͥ͂‫ه‬ఴͅచ؊̳̹ͥ͛ͅȂߓఘഎ̈́࿒ດͬ୭೰̱Ȃచॐͬ৘࣐
̱̹ࢃȂ̷͈࢘‫ͬض‬ບ‫̹̱̭̳͂ͥͅث‬ȃߓఘഎ̈́࿒ດ̱͉͂̀Ȃ୆‫ڰ‬ਠ‫۝‬ພ̷̤͍͢
͈อછȆૺ࣐ͅ‫۾‬ဓ̱̞̀ͥ୆‫ڰ‬ਠ‫͈۝‬٨஝൝ͅ‫ه̳ͥ۾‬ఴͬ஖೰̱Ȃ‫ူו‬Ȇ૙୆‫ڰ‬Ȃ૸ఘ‫ڰ‬൲Ȇ‫׋‬൲Ȃ‫ူݝ‬Ḙ̭͈̑ͧ࠲ࢫ̩̿ͤȂ̹̭͊Ȃͺσ΋ȜσȂভ͈࠲ࢫȂൠෂພȂ੏۪‫ܕ‬ພȂ̦͈ͭ 9 ໦࿤̤̞̀ࠗͅ 70 ࣜ࿒̹ͩͥͅߓఘഎ̈́࿒ດ̦୭೰̯̹ͦȃ̯ͣͅȂ୆‫ڰ‬ਠ‫̩ͤ̿ࢫ࠲͂۝‬Ȇ৖ພထཡ͈͂‫ڠش̳ͥ۾ͅ߸۾‬എ౶ࡉ͈ಇୟͬ଎ͤȂ‫ڠش‬എआ‫ڰ̩̿ܖͅݶ‬൲̳̭͂ͥ͂Ȃ࿒ດ͈ૺജഽͬ 10 ΃ාْ͈ࠗಎ‫ۼ‬ത̜́ͥ 2005 ාͅಎ‫ۼ‬ບ‫̹̱̭̳͂͂ͥث‬ȃȶ࠲ࢫ඾ུ 21ȷ͈ಎ‫ۼ‬ບ‫̦ުै͈ث‬Ȃ࢚୆‫݈ૣڠش‬ٛ౷֖༗࠲࠲ࢫ
௩ૺ‫ူו‬໐̤̞ٛ̀ͅ 2004 ා 10 ࠮̥ͣૺ̹͛ͣͦȃ൳໐͉ٛȂ൳শ̭͈ͦ́͘ͅ୆‫ڰ‬ਠ‫۝‬ພచॐ͈࡛ે͂‫ه‬ఴ̤͍ࣽ͢ࢃ͈༷࢜଻̞̾̀ͅૣ݈̱Ȃ2005 ා 9 ࠮ͅȶࣽࢃ͈୆‫ڰ‬ਠ‫۝‬ພచॐ͈ଔૺ̞̾̀ͅ(ಎ‫͛͂ͤ͂͘ۼ‬ȫȷͬ࢖ນ̱̹ȃ̷͈ါത͉ȂιΗδςΛ·ΏϋΡυȜθ͈‫ٽ‬ැͅ‫૷࠲̩̿ܖ‬Ȇ༗࠲ঐ൵͈൵වȂ࠲૷‫ܥ‬͈ٛ౲‫͂اٴ‬༗࠲ঐ൵͈‫ٴ‬௄‫ا‬Ȃ ‫ڠش‬എआ‫̩̿ܖͅݶ‬༗࠲ঐ൵͂༗࠲ঐ൵ίυΈρθ͈ດ੔‫̜ͥ́ا‬ȃྕ଻৖͈ۛ
చॐ͈̹͈͛අ೰࠲૷Ȇඅ೰༗ࡏমު͈ࣸ‫̦ڒ‬া̯̞ͦ̀ͥȃ̠͉͌͂̾͜Ȃ़ଽ࿒എ͈̹͈͛ȶ֓ၷ๯ഐୃ‫ا‬ȷ̜́ͥȃ2005 ා 10 ࠮ 4 ඾͈ࠐफ़ଽন࿚݈࢚ٛ́୆Ⴛ൱ఱ૳̦౤എͅ୰ྶ̱̞̀ͥȃ̳̻̈́ͩȂȶൠෂພ൝͈୆‫ڰ‬ਠ‫۝‬ພ͈ᑋۛ৪̦௩ఱ̱௽̫̤̀ͤȂ‫ح̢̀ح‬Ⴂ͂͂͜ͅ୆‫ڰ‬ਠ‫۝‬ພ̦௩՛̱̀ෞࢸणȂ૤޼ࢸण൝ͬอછ̳ͥΉȜΑ͜௩ఱ̱̞̀ͥȃ̭̠̱̹ࢹ௮എ̈́ါ֦̈́̓ͤ͢ͅȂჇ૽֓ၷ๯ͬಎ૤֓ͅၷ๯͈૝͍̦ࠐफ͈૝͍ͬષ̞ٝ̽̀ͥȃ̭͈̹͛Ȃ֓ၷ๯ഐୃ‫͛ૺͬا‬̹͉ͥ͛ͅȂ୆‫ڰ‬ਠ‫۝‬ພ͈̈́̓֓ၷ͈૝͍͈ࢹ௮എ̈́ါ֦ͅ಍࿒̱̀Ȃ࣭͂സൽຸࡇ̦
‫ފ‬ႁ̱Ȃۛ৪Ȃ֓ၷ‫۾ܥ‬Ȃঌ಴ఆͬ‫̹֓͛܄‬ၷ༗ࡏ৪̷̸͈ͦͦ͜࿨‫̦̱̹ͣ̈́ضͬڬ‬Ȃ֓ၷ๯ഐୃ‫ͬا‬ଔૺ̳̭̦ͥ͂ഐ୨̜́ͥȃ̭ͦͤ͢ͅȂ࣭ྦྷ͈୆‫͈ڰ‬ৗͬ‫ږ‬༗Ȇ࢜ષ̱̾̾Ȃ֓ၷ̷͈͈ͬ࢘͜ၚ‫̱ا‬Ȃ֓ၷ๯͈૝͍ͬ੭șͅ‫̧̦̭̬ͥ́͂ͥئ‬ȃ
ȷ֓ၷ๯

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͈૝͍ͬဲଷ̳͈̦ͥȂଽॐ࿒ດ̯̹͈̜͂ͦ́ͥȃ̱̥̱Ȃ࣭ٛૣ݈͈ા̤̞̀͜ͅ
֓ၷ๯͈ဲଷͅࠒ̦͈ͥ͂ྶ‫΀̹̱͂ࡥږ̥̾ږ‬ΫΟϋΑ͉া̯̥̹ͦ̈́̽ȃ̹͘Ȃ২ٛ༗વ๯ဥဲଷଽॐ͈͒చ؊ॐ̱͂̀ഐ୨̥Ȃଽॐ৘࡛͈ࡉ೒̱͂΋ΑΠ̦͈̓೾ഽͅ
̥̞̈́ͥ̾̀͜ͅ਱໦݈ͅა̢̦̯̹͉̞̥̹̈́ͦ͂̈́̽ȃఱܰ࿅̈́ଽॐജ‫ͬٳ‬଎͉ͥͅȂ΀ΫΟϋΑະ௷͈̥̈́́‫̹̯࣐ͦޑ‬࿂̦‫̜̩ͥޑ‬ȃ! ӲΰσΑΉͺͅ‫̳ͥ۾‬ଽॐ̱͈͂̀අಭ
a.! ֓ၷ๯ဲଷ͈࿒ດ
֓ၷ๯ॉࡘͬ࿒ດ̱̹͂Ȃఈ͈মުଽॐ͈͂Ⴒࠈ̦ྶা̯̞̞ͦ̀̈́ଽॐ̜́ͥȃb. ထཡ͈ႀ֖
! ! ֚ষထཡ͈̠̻Ȃ֓ၷ࣐և̞͂̈́ͣ̈́࠲ࢫ௩ૺ‫ڰ‬൲ႀ֖̜̭̦́ͥ͂අಭ̜́ͥȃఈ͈࣭͉́ȂඵষထཡȂ२ষထཡ́͘‫̦̭͂ͥͦ͘܄‬ఉ̞ȃߓఘഎ͉ͅȂȶ࠲ࢫ඾ུ21ȷ͈࠲ࢫ௩ૺȆ৖ພထཡমު͈ࡉೄ̱ͅࠒ̦ͥȃ2005 ා 9 ࠮࢚୆‫݈ૣڠش‬ٛ౷֖༗࠲࠲ࢫ௩ૺ‫ူו‬໐͈ٛಎ‫͛͂ͤ͂͘ۼ‬ȶࣽࢃ͈୆‫ڰ‬ਠ‫۝‬ພచॐ͈ଔૺ̞̾̀ͅȷ
͉ȂιΗδςΛ·ΏϋΡυȜθ͈‫ٽ‬ැͅ‫૷࠲̩̿ܖ‬Ȇ༗࠲ঐ൵͈൵වȂ࠲૷‫ܥ‬͈ٛ౲‫͂اٴ‬༗࠲ঐ൵͈‫ٴ‬௄‫ا‬Ȃ‫ڠش‬എआ‫̩̿ܖͅݶ‬༗࠲ঐ൵͂༗࠲ঐ൵ίυΈρθ͈ດ੔‫̹͛ݥͬا‬ȃc. ٚව঑‫׳‬చયਬ౬ٚව঑‫׳‬చયਬ౬ͬȂා႓́ߊ୨̹̽஠࣭ྦྷ̱̞͂̀ͥത͉Ȃޭ͛̀අಭഎ̜́ͥȃ ུ༭࣬́৾ͤષ̬̹୶ૺ࣭͉Ȃඅ೰͈ਬ౬Ȫ౷֖̈́̓ࡠ೰എȫͅచ̱̀ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦৘ঔ̯̞͈ͦ̀ͥ͂๤̳ͥ͂ޭ͛̀අ։̜́ͥȃ̹͘Ȃ֓ၷ༗ࡏ৪̦ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ͈৘ঔ৽ఘ̈́ͥͅম႕͉
ఉ̞̦Ȃහփͅ৘ঔ̱̞̀ͥȃ༹ၙ̽̀֓͢ͅၷ༗ࡏ৪͈݅ྩ‫̹࣐̽ͬا‬ത͜ఈ͉̞́̈́৘ঔ༹༷̜́ͥȃd.! ͼϋΓϋΞͻή͈୭ࠗ֓ၷ༗ࡏ৪͉́Ȃ̷͈చય̳͂ͥ‫ح‬ව৪ਬ౬ͅచ̱̀ίυΈρθͬ৘ঔ̱Ȃ‫ح‬ව৪͈࠲ࢫςΑ·ͬ٨஝̱Ȃ୆‫͈ڰ‬ৗ͈࢜ષ̜̞͉ͥ༗ࡏ़ଽഎ̈́࢘‫ͬض‬৘࡛̳̭ͥ
̦͂ఉ̞ȃ֓ၷ༗ࡏ৪̦৘ঔ̳ͥίυΈρθ͉́Ȃ̷͈࢘‫͉֓ض‬ၷ༗ࡏ৪̜̞͉ͥ
‫ح‬ව৪ͅ‫๊̦͈̳֚ͥ௺ܦ‬എ̜́ͥȃ̱̥̱Ȃུ࠯͉́ȂίυΈρθ৘ঔ৽ఘͅȂ༆͈ଷഽ͈͒঑‫߄׳‬঑໡ͅ‫̱۾‬ȂίυΈρθ͈৘࣐೾ഽͅ؊̲̹‫ͬॳࡘॳح‬ழ͙ࣺ̤ͭ́ͤȂু͈ͣ၌‫ͼ̞̦̈́ͣࠒͅף‬ϋΓϋΞͻή୭̞ࠗ͂̈́̽̀ͥത̦අಭ̜́ͥȃ
d.! ْࠗၛմ৪Ȇ๯ဥ໅౜৪͈௖֑
ଽॐၛմ৪͉ಎ؇ଽຸ̜̦́ͥȂ֓ၷ༗ࡏ৪̦๯ဥ໅౜৪̞͂̈́̽̀ͥത͉අಭ
എ̜́ͥȃ֓ၷ༗ࡏ৪͉̳́ͅ࠲૷ͬ৘ঔ̱̤̀ͤȂ༗࠲ঐ൵মުͬັ‫̭̳͂ͥح‬́Ȃ๯ဥ໅౜͉ผఱ̞͈̈́ͣ̈́͂ͅࡉ೒̱̦̜̹͈̽͂͜ࣉ̢ͣͦͥȃಎ؇ଽຸ͉Ȃఉઁ़͈࡙ͬဥփ̱̀༞੩߄ͬ࢐ັ̱̹̺̫̜̹́̽ȃ-71-

e.! ౙ֚κΟσ͈֚୔ജ‫͈ٳ‬৘ঔ༹༷ίυΈρθ͈ুဇഽ̦ޭ͛̀೩̞ȃࠐࡑ̦̞̈́֓ၷ༗ࡏ৪݅ͅྩ‫̹̹̱͛ا‬ȂίυΈρθ͈ඤယͬજ႓́મळͅࠨ͛Ȃ೰߿എ̈́ඤယ̱̞͂̀ͥȃ৘ঔ༹༷͉Ȃಎ؇ਬࡀഎ̜́ͤȂౙ͈֚৘ঔ༹༷̱̥ယ෇̵̴Ȃఉအ଻Ȇ‫خ‬ෝ଻ͬম৘ષ๛೰̱̞̀ͥȃ
! ! f. ιΗδςΛ·ΏϋΡυȜθιΗδςΛ·ΏϋΡυȜθͬΗȜΊΛΠ̳͂ͥίυΈρθͬनဥ̱̞̭͉̀ͥ͂
ఱ̧̈́අಭ̜́ͥȃྕ଻৖ۛ࿚ఴ͈͒৾ழ̦ൠෂພ൝৖ۛౙպ̯̭̦̈́ͦͥ͂ͅఉ
̞͈ͅచ̱̀Ȃ৖ۛࡔ֦͈ષၠ̧̞̠͓͂͜തͅઙതͬ൚̞̀̀ͥത࢘ͅ‫ܢ̦ض‬ఞ̧́ͥȃ㧔㧞㧕ᣣᧄߩ․ቯஜ⸻࡮․ቯ଻ஜᜰዉ੐ᬺߩ᡽╷⺖㗴ӱଽॐജ‫ٳ‬κΟσ͂ଽॐ࿒ດ͈ࡉೄ̱
! ! ΟͻΐȜΒζΥΐιϋΠȆίυΈρθ̦൚੝‫ܢ‬ఞ̯̞̹͕͈ͦ̀̓අ༆͈๩ྟ໶‫́ܕ‬͉̞̭̦̈́͂੭șͅྶ‫̯ͥͦͅاږ‬ਲ̞ȂίυΈρθ͈࢘‫̷͈͂ض‬ίυΈρθͬఱܰ࿅ͅജ‫̳ͥٳ‬ଽॐ̷̷̞̾̀࢘͜͜ͅ‫ض‬Ȇ࿒ດ͈̠ͬ̓͢ͅ୭೰̳͈̦ͥഐ൚̥͈͂‫ه‬ఴ̦୆̲̞̀ͥȃίυΈρθͬഐဥ̱൚࿂଼͈‫̱̀͂ض‬ౙอഎ̈́֓ၷ๯͈૝͍ͬဲଷ̧́
̹̱͂̀͜Ȃ̷̦ͦଽॐജ‫͉̥̠̥̓ض͈࢘ٳ‬฻౯̳͈͉ͥࣾඳ̜́ͥȃඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵মު͉́Ȃ࠲ࢫ௩ૺ৘ঔͥ͢ͅ 5 ා‫͈ۼ‬ບ‫̠̞͂ث‬Ȃ୯ࡘ࢘‫ͬض‬ே೰̱֓ၷ
๯ဲଷͬଽॐ࿒ດ̳̭̞͈̥͂ͥ͂́ͬ͢ठ࠿൦̳ͥຈါ଻͜࠿൦‫ه‬ఴ̈́ͥͅȃ࿔აȂఱ̧̈́ଽॐജ‫̥͈̈́ͅٳ‬ίυΈρθͬनဥ̳̭͉̜ͥ͂ͤං̦ͥȂຈ̴̱͜ίυΈρθ
ജ‫͈ٳ‬ଽॐౙఘ́ບ‫̳ͥث‬ຈါ͉̞̈́ȃ̹͘Ȃಿ‫ܢ‬എͅΉͺͬ೹‫̱ރ‬Ήͺ͈࢘‫௶ͬض‬೰̳ͥκΟσ͉̩́̈́Ȃౣ‫ܢ‬എͅহၷ࢘
‫͈ض‬ບ‫ܢ଻ݢ̧̦ͥ́ث‬എ̈́হၷ࣐̠ͬκΟσͬճ࿑͈ே೰̱̹͂ജ‫خ̹̞̀̽̈́͂ٳ‬ෝ଻̦̜ͥȃ̱̥̱Ȃଽॐచય̞͂̈́̽̀ͥྕ଻৖͉ۛ́୆‫ڰ‬ਠ‫۝‬٨஝ࠑ௽̷͈͂࢘‫ض‬̞̠͂ಿ‫ܢ‬എ̈́ΑΩΰ࢘‫௶ض‬೰͂ບ‫̦ث‬ຈါ̜́ͤȂౣ‫ܢ‬എ̈́࢘‫́ض‬฻౯̦̭̓́͘
ഐ൚̥࠿൦̳ͥຈါ̦̜ͥȃ! Ӳ঩࡙Ȇࠐࡑழ૕ෝႁ࿚ఴ
! ! ίυΈρθͬ৘ঔ̱̀࢘‫͉̬̜ͥͬͅض‬Ȃಎಿ‫ܢ‬എ̈́঩࡙ൎව͈ࠑ௽̦ຈါ̜́ͥȃඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵মު́Ȃ̭̦̯̹̥ͦ̈́ͦ݃࿚̦̜ͥȃଽॐജ‫͉̳ͥͬͅٳ‬Ȃ௖؊͈঩࡙ൎව̳̥̜̞͉ͬͥͥಿ‫ْࠗܢ‬ॐ೰͈ષْࠗഎͅൎව̳̭ͥ͂ͬࣉ̢ͥຈါ
̦̜ͥȃ̹͘Ȃඅ೰࠲૷Ȇඅ೰༗࠲ঐ൵মުͬఉ̩͈֓ၷ༗ࡏ৪̦৘ঔ̱̹̭͉͂Ȃ֓ၷ༗ࡏ৪̤̫ͥͅࠐࡑ౶͈ಇୟ̦ૺ̺ͭ͂͜ࣉ̢͈ͣͦͥ́Ȃ̷͈ࠐࡑ౶͈อജജ‫ͬٳ‬଎ͥଽॐࣽ͜ࢃခ̜̠࢘́ͧȃ! ӳͼϋΓϋΞͻή͂‫ڰ‬൲ບ‫!ث‬! ΟͻΐȜΒȆζΥΐιϋΠ͉́Ȃ̷̸͈ͦͦ൚ম৪͈ͼϋΓϋΞͻήͬ୭̳ࠗͥຈါ

-72-̦̜ͤȂࠑ௽എͅ৘ঔ̳͉ͥͅਹါ̈́ത̜́ͥȃఈଷഽ͈͒‫ͼ̠̞͂ॳࡘॳح͈߄੄ݶ‬ϋΓϋΞͻή୭͉ࠗȂ̷̸͈ͦͦ൚ম৪͈ႁၾ̦͕͖୔̜֚́ͤȂౣ‫ܢ‬എͅවͦఢ̢̦
‫خ‬ෝ̈́ાࣣ͉ͅခ࢘ͅ‫ܥ‬ෝ̳̦ͥȂႁၾ̦ະ௷̱̞̀ͥ֓ၷ༗ࡏ৪̦೏‫͈ح‬໅౜̳ͬͥ
̭͉͂‫ף‬șႁၾ͈Ⴆ‫ͬا‬ઉ̩‫̜̦ͥͦޔ‬ȃͼϋΓϋΞͻήͬ୭̳͉ࠗͥͅȂ൚ম৪̦ୟ
ޭഎͅষ͈٨஝৾ͤͅழ͚༷̥̠̠࢜࢜͢ͅͅ෻ၪ̳̭ͥ͂͜ຈါ̈́ͥͅȃ̹͘Ȃ̱֓͜ၷ༗ࡏ৪̦ȂΕέΠ̈́ထॳଷ࿩‫̜͊ͦͅئ‬Ȃ̷͈ͼϋΓϋΞͻή͉‫ܥ̩ޑ‬ෝ̳̥ͥ݃
࿚̦̜ͥȃ! Ӵone fits all ༷ૻ͈ࡉೄ̱͂ͼΦαȜΏοϋ௯ૺίυΈρθ̦ခ࢘࢘ͅ‫͉̬̜ͥͬͅض‬Ȃ̷͈শ̷͈ા͈́ࡢ༆ٜͬอࡉ̱৘ঔ̳̭ͥ
̦͂ຈါ̜́ͥȃOne fits all ͉৘षഎ̞́̈́ȃٚවশ‫ۼ‬ତȆٚව༹༷͈̈́̓ίυΈρθ
͈મळͬ࣬া൝́೰֚͛ၙ৘ঔͬ‫༷ͥ͛ݥ‬৆͉́Ȃ࢘‫ܢ̦ض‬ఞ̧̞̥̥࡛́̈́͊ͤા౶
͈ညอ͈ΙλϋΑͬ৐̠̭̥͇̞͂̈́ͤ̈́ͅȃͼΦαȜΏοϋͬ௯ૺ̱Ȃͤ͢ၻ̞࢘‫ض‬എ̈́ίυΈρθͬജ‫͉̹̳͛ͥͅٳ‬Ȃ࡛ા͈ুဇഽवၾഽ༷̦ͬࣞ͛ͥ৘࢘଻ͬ‫ܢ‬ఞ́
̧ͥȃ


-73-

ΟͻΐȜΒȆζΥΐιϋΠଽॐ‫ه‬ఴࡄ‫ݪ‬͈ٛࡄ‫ڰݪ‬൲Ƀࡄ‫ݪ‬տ֥Ʉ
Ȫजಿȫനಎস! ࠄᑄ݅ੂఱ‫ڠ‬ఱ‫ۯאࠐ֭ڠ‬ၑࡄ‫ޗ !شݪ‬਎Ȫտ֥ȫઐന૨ढ! ॲު֓‫ش‬ఱ‫࢖ڠ‬ਤ‫מ‬୆‫ޗڠ‬৒! ‫ޗ‬਎ा‫ࢬے‬෗! ྴઽఱ‫ڠ‬࿪‫ڠ‬໐ႉ઄ࠐफ‫ݪࡄڠ‬৒! ‫ޗ‬਎૩५๼౶ঊ! ࢩോఱ‫ڠ‬ఱ‫֭ڠ‬༗࠲‫شݪࡄڠ‬༗࠲‫ٳࢌۭࢲ୺ڠ‬อ‫࣒ڠش‬ज! ‫ޗ‬਎
Gregg L. Mayer! Gregg L. Mayer & Company, Inc. President! Dr.
࿒ࣱ઎֚჊! Ⴁᚧఱ‫ڠ‬ఱ‫࣭֭ڠ‬षࠐफࡄ‫ޗ شݪ‬਎
૯࿤ੇਏ! ఉླྀఱ‫ޗ !ڠ‬਎‫࢛ع‬ဢ࣐! ଼ઽఱ‫ࠐڠ‬फ‫ڠ‬໐! ‫ޗ‬਎
നઽࢣဎ! ਜ਼ഛ൴ఱ‫ڠ֓ڠ‬໐Ȇఱ‫ !شݪࡄڠ֭֓ڠ‬੎‫ޗ‬਎! ਜ਼ഛ൴ఱ‫ڠ‬ΑεȜΜ࠲ࢫ‫ڠ‬໐Ȇ༗࠲ۭࢌ‫ڠ‬໐! ‫ޗ‬਎
໹֔Ք५! ୷ဩࡇၛ൐߄ພ֭֭ಿ
್ྴୃਏ! ࠲ࢫ༗ࡏழࣣႲࣣٛၑম
‫ུޘ‬Ꭿ୆! ‫؍‬ຩঌၛఱ‫௺ັڠ‬ພ֭! ֓ၷհ஠‫ۯ‬ၑ‫ޗ !ڠ‬਎‫ུ࿆ؖ‬ဎ! ΓϋΠΉͺȆγȜσΟͻϋΈ‫ڼ‬৆ٛ২! ৏࣐࿨֥઀ႅඈ! అ༗ΐλΩϋ௙ࣣࡄ‫ݪ‬ਫ਼! έ͹΃σΞͻέͿυȜɃমྩޫɄఅ༗ΐλΩϋ௙ࣣࡄ‫ݪ‬ਫ਼Ƀࡄ‫ݪ‬͈ٛ࿒എɄ
! ΟͻΐȜΒȆζΥΐιϋΠȪո‫ئ‬ȶDMȷ̞̠͂ȫ͉ۛ৪֓͞ၷίυΨͼΘȜͅచ̳ͥ঑
‫̭̠࣐̀̽͂ͬ͢ͅ׳‬Ȃ૷ၷȆၷူ͈࢘‫͂͂ͥ͛ࣞͬ͜ͅض‬Ȃ֓ၷ๯͈࿂́͜डഐ‫ͬا‬଎̹͈ͥ͛৾ழ̜́ͤȂ඾ུ̤̫ͥͅ DM ͈อജ͉Ȃ֓ၷ঩࡙෻໦͈डഐ‫ͬا‬೒̲̀Ȃ࣭ྦྷ͈ࢨ໛͈௩ఱ̦̾̈́ͥ͂ͅࣉ̢ͣͦͥȃ༷֚Ȃ࡛ह͈඾ུ͉́ȂDM ࣐̠̹ͬ͛ͅຈါ̈́‫ܖ‬๕̦ା̞̞̽̀̈́ે‫̹̜͛ͥͅޙ‬Ȃུࡄ‫ݪ‬͉ٛ́Ȃ඾ུ̤̞̀ͅ DM ͬอജ̵̯̹͈ͥ͛
ଽॐ‫ه‬ఴ̱͂̀ȂDM ͅຈါ̈́‫ܖ‬๕͈ା๵̞̾̀ͅࡄ‫̳ͥݪ‬ȃɃࡄ‫ݪ‬ٛ‫ٳ‬टܱ჏Ʉల 1 ٝȪ2005 ා 10 ࠮ȫల 6 ٝȪ2007 ා˓࠮ȫల 2 ٝȪ2005 ා 12 ࠮ȫల 7 ٝȪ2008 ා 11 ࠮ȫల 3 ٝȪ2006 ා 3 ࠮ȫ

ల 8 ٝȪ2008 ා 12 ࠮ȫల 4 ٝȪ2006 ා 6 ࠮ȫ

ల 9 ٝȪ2009 ා 3 ࠮ȫ

ల 5 ٝȪ2006 ා 11 ࠮ȫల 10 ٝȪ2009 ා 6 ࠮ȫ-74-ల 11 ٝȪ2009 ා 11 ᦬㧕ల 13 ٝȪ2011 ා 11 ࠮ȫల 12 ٝȪ2010 ා 3 ࠮ȫɃΏϋεΐ;θ‫ٳ‬टܱ჏Ʉ
2006 ා 1 ࠮ȶ̭̥͈ͦͣ୆‫ڰ‬ਠ‫۝‬ພచॐ͈̜༷ͤͬౝͥȽༀ࣭͈ιΟͻΉͺȂιΟͻΉͼΡ̤̫ͥͅΟͻΐȜΒȆζΥΐιϋΠȆίυΈρθ൵ව̥ͣ‫͐ڠ‬ȷɃུ༭࣬੥̞̾̀ͅɄ
! ུ༭࣬੥͉‫ڎ‬͈ٝࡄ‫ݪ‬̤̫ٛͥͅอນ৪͈༭̤͍݈࣬͢აͬ൩̢̀͘ै଼̯̞ͦ̀ͥȃ̹̺̱Ȃུ༭࣬੥͈ै଼̜̹͉̽̀ͅȂࡄ‫ݪ‬տ֥̤͍͢মྩޫ͈ιϋΨȜ̀ͅ໦౜̱̀৏
ຊ̳̭̱̹ͥ͂͂ȃ৏ຊ໦౜͉Ȃల 1 ડȂల 2 ડల 1 ୯Ȃల 3 ୯Ȃల 5 ୯Ȃల 6 ୯̤͍͢
ల 3 ડ̦ࡄ‫ݪ‬տ֥͈઀ႅඈȂల 2 ડల 2 ୯̦઀ႅ͂মྩޫ͈‫ݛ‬ংຮঃȂల 2 ડల 4 ୯Ȃల
7 ୯̦‫ݛ‬ংȂల 2 ડల 8 ୯̦ࡄ‫ݪ‬տ֥͈ा‫ࢬے‬෗̞͂̈́̽̀ͥȃ
ո! ! ષ

-75-

損保ジャパン記念財団叢書 №៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅ฌᦠ  0Q៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅ฌᦠ 0Q‫࠻ࡦࡔࠫࡀࡑ࡮࠭࡯ࠫࠖ࠺ޟ‬᡽╷⺖㗴⎇ⓥળ‫ޠ‬ႎ๔ᦠ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻ߦ㑐ߔࠆ᡽╷ߩ࿖㓙Ყセ﹁ディジーズ・マネジメント政策課題研究会﹂報告書 ディジーズ・マネジメントに関する政策の国際比較

82‫࠻ࡦࡔࠫࡀࡑ࡮࠭࡯ࠫࠖ࠺ޟ‬᡽╷⺖㗴⎇ⓥળ‫ޠ‬ႎ๔ᦠ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻ߦ㑐ߔࠆ᡽╷ߩ࿖㓙Ყセ࠺ࠖࠫ࡯࠭࡮ࡑࡀࠫࡔࡦ࠻᡽╷⺖㗴⎇ⓥળᐳ㐳 ↰ਛ ṑ㧔ᘮᔕ⟵Ⴖᄢቇᄢቇ㒮ᢎ᝼㧕







 ⊒ⴕ⠪  ౏⋉⽷࿅ᴺੱ ៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅      ‫᧲ ޥ‬੩ㇺᣂኋ඙⷏ᣂኋ㧝㧙㧞㧢㧙㧝 㔚 ⹤      㧲㧭㨄  
 74.   JVVRYYYULHQWPFCVKQPQTI

公益財団法人損保ジャパン記念財団

 ⊒ⴕᣣ  ᐔᚑ㧞㧠ᐕ㧟᦬㧟㧜ᣣᐔᚑ㧞㧠ᐕ㧟᦬౏⋉⽷࿅ᴺੱ ៊଻ࠫࡖࡄࡦ⸥ᔨ⽷࿅