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2013 Fiscal Year Final Research Report

Development of the new chronic disease care provision model by expanding roles of nurses and medical insurance holders

Research Project

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Project/Area Number 22249069
Research Category

Grant-in-Aid for Scientific Research (A)

Allocation TypeSingle-year Grants
Section一般
Research Field Clinical nursing
Research InstitutionHiroshima University

Principal Investigator

MORIYAMA Michiko  広島大学, 医歯薬保健学研究院(保), 教授 (80264977)

Co-Investigator(Kenkyū-buntansha) YOSHIDA Toshiko  宮城大学, 看護学部, 教授 (60325933)
NAKASHIMA Naoki  九州大学, 大学病院, 准教授 (60325529)
OKA Michiyo  群馬大学, 保健学研究科, 教授 (10312729)
KIHARA Yasuki  広島大学, 大学院医歯薬保健学研究院(医), 教授 (40214853)
YORIOKA Noriaki  広島大学, 医歯薬学総合研究科, 教授 (40144828)
KAMOUCHI Masahiro  九州大学, 医学(系)研究科(研究院), 教授 (80346783)
KARIBE Akihiko  宮城大学, 看護学部, 教授 (80359504)
YOKOYAMA Yukio  広島大学, 大学病院, 病院助教 (40508157)
Project Period (FY) 2010-04-01 – 2014-03-31
Keywords慢性病看護学 / 疾病管理 / ポピュレーション・ヘルス・マネジメント / 慢性疾患 / アルゴリズム
Research Abstract

In this study, a project was implemented to prevent progression of chronic diseases. In order to achieve this, continuity of care for chronic disease patients was secured, stratified logic was utilized which allowed for appropriate allocations of medical resources, and a Chronic Disease Care Provision Model was designed and developed. The model offers evidence-based care.
More specifically, a disease management center was set up, which supported medical insurance holders and medical institutions and where nurses with specialized education were stationed. Moreover, the group of medical insurance holders was stratified and a disease management program was formulated, which was deemed to be necessary for each stratum. Thus, a mechanism was built in order to cover from primary to tertiary prevention.

  • Research Products

    (36 results)

All 2014 2013 2012 2011 2010 Other

All Journal Article (15 results) (of which Peer Reviewed: 13 results) Presentation (10 results) Book (4 results) Remarks (7 results)

  • [Journal Article] 36-month follow-up study of post-intervention chronic heart failure patients2014

    • Author(s)
      Haruka Otsu, Michiko Moriyama
    • Journal Title

      Health

      Volume: 6 Pages: 559-575

    • Peer Reviewed
  • [Journal Article] Assessment of a portfolio as an effective tool to promote self-management among patients with ischemic heart diseases : A preliminary trial2014

    • Author(s)
      Otsu H., Moriyama M., Yuasa R., & Omori T.
    • Journal Title

      Health

      Volume: 6(5) Pages: 364-373

    • Peer Reviewed
  • [Journal Article] Effects of a self-management skills-acquisition program on pre-dialysis patients with diabetic nephropathy2013

    • Author(s)
      Kazawa K, Moriyama M.
    • Journal Title

      Nephrology Nursing Journal

      Volume: 40(2) Pages: 141-149

    • Peer Reviewed
  • [Journal Article] 循環器領域における疾病管理の実際2013

    • Author(s)
      森山美知子,水川真理子
    • Journal Title

      Heart View

      Volume: 18 Pages: 62-69

  • [Journal Article] Effects of a 6-month nurse-led self-management program on comprehensive pulmonary rehabilitation for patients with COPD receiving home oxygen therapy2013

    • Author(s)
      Moriyama M., Takeshita Y., Haruta Y., Hattori N., & Ezenwaka E.C.
    • Journal Title

      Rehabilitation Nursing

    • DOI

      10.1002/rnj.119

    • Peer Reviewed
  • [Journal Article] MacNew Heart Disease Health-Related Quality of Life Questionnaire日本語版の信頼性・妥当性の再検討 -心筋梗塞患者による再検討-2013

    • Author(s)
      大津美香, 森山美知子, 中谷隆
    • Journal Title

      日本循環器看護学会誌

      Volume: 9(1) Pages: 100-108

    • Peer Reviewed
  • [Journal Article] Multifactorial analysis of factors affecting recurrence of stroke in Japan2012

    • Author(s)
      Omori T, Kawagoe M, Moriyama M, Yasuda T, Ito Y, Hyakuta T, Nagatsuka K, Matsumoto M.
    • Journal Title

      Asia Pacific Journal of Public Health

    • DOI

      1010539512441821

    • Peer Reviewed
  • [Journal Article] 保存期糖尿病腎症患者に対する教育プログラムの効果(6か月間の介入評価)2012

    • Author(s)
      加澤佳奈,森山美知子
    • Journal Title

      日本腎不全看護学会誌

      Volume: 14(2) Pages: 92-100

    • Peer Reviewed
  • [Journal Article] Follow-up study for a disease management program for chronic heart failure 24 months after program commencement2012

    • Author(s)
      Otsu H, Moriyama M
    • Journal Title

      Japan Journal of Nursing Science

      Volume: 9(2) Pages: 136-148

    • Peer Reviewed
  • [Journal Article] 軽症脳梗塞患者の再発予防における自己管理の実態と臨床指標との関連2012

    • Author(s)
      福岡泰子,百田武司,大森豊緑,森山美知子
    • Journal Title

      広島大学保健学ジャーナル

      Volume: 11(1) Pages: 1-9

    • Peer Reviewed
  • [Journal Article] Effectiveness of an educational self-management program for outpatients with chronic heart failure2011

    • Author(s)
      Otsu, H., & Moriyama, M.
    • Journal Title

      Japan Journal of Nursing Science

      Volume: 8 Pages: 140-152

    • Peer Reviewed
  • [Journal Article] オールバリアンス方式アウトカム志向型電子パスとバリアンス分析の実際 : クリティカルインディケーターの探索的抽出の試み2011

    • Author(s)
      若田好史, 中島直樹, 萩原明人
    • Journal Title

      日本クリニカルパス学会誌

      Volume: 13 Pages: 209-213

    • Peer Reviewed
  • [Journal Article] 情報爆発時代のヘルスケア2011

    • Author(s)
      井上創造, 中島直樹
    • Journal Title

      電子情報通信学芸誌

      Volume: 94 Pages: 700-705

    • Peer Reviewed
  • [Journal Article] 地域における糖尿病医療連携パスの現状 糖尿病疾病管理のための地域医療連携クリティカルパス2011

    • Author(s)
      小林邦久, 中島直樹, 井口登與志, 髙栁涼一, 名和田新
    • Journal Title

      Diabetes Frontier

      Volume: 22 Pages: 130-135

  • [Journal Article] 慢性期虚血性心疾患患者の自己管理行動評価尺度の作成2011

    • Author(s)
      大村由紀美, 森山美知子, 中野真寿美, 二井谷真由美
    • Journal Title

      日本循環器看護学会誌

      Volume: 6(2) Pages: 19-27

    • Peer Reviewed
  • [Presentation] The role of advanced practice nurse in development and implementation of disease management system for population of CHF patients in Hiroshima prefecture in Japan2013

    • Author(s)
      Mariko Mizukawa, Michiko Moriyama
    • Organizer
      3rd World Academy of Nursing Science
    • Place of Presentation
      Seoul, Korea
    • Year and Date
      2013-10-18
  • [Presentation] Telemonitoring in patients with chronic heart failure : The interim report of an ongoing prospective multicenter randomized trial in Japan (Pilot Study)2013

    • Author(s)
      Mariko Mizukawa, Makiko Shimomura, Miyuki Tomiyama, Tamie Tanabe, Shizue Kobayashi, Yasuki Kihara, Michiko Moriyama
    • Organizer
      3rd World Academy of Nursing Science
    • Place of Presentation
      Seoul, Korea
    • Year and Date
      2013-10-18
  • [Presentation] Effects of physiological indicators and self-management goal attainment on the cerebral infarction recurrence prevention program : results of the intervention and 6 Month- follow-up2013

    • Author(s)
      Yasuko Fukuoka, Takeshi Hyakuta, Masayasu Matsumoto, Kazumi Kimura, Michiko Moriyama
    • Organizer
      9th International Nursing Conference
    • Place of Presentation
      Seoul, Korea
    • Year and Date
      2013-10-16
  • [Presentation] Challenges of Telemedicine Development Center of Asia in Kyushu University2013

    • Author(s)
      Naoki Nakashima
    • Organizer
      Digital Healthcare World Asia 2013
    • Place of Presentation
      Singapore, Singapore
    • Year and Date
      2013-10-10
  • [Presentation] 看護師による慢性疾患管理 : ソーシャル・アントレプレニュアーシップ2012

    • Author(s)
      森山美知子
    • Organizer
      第17回日本糖尿病教育・看護学会学術集会
    • Place of Presentation
      京都
    • Year and Date
      2012-09-30
  • [Presentation] 在宅から医療機関まで情報連携する医療と疾病管理2011

    • Author(s)
      中島直樹, 野原康伸, 井上創造, 小林邦久, 井口登與志
    • Organizer
      第28回日本医学総会
    • Place of Presentation
      東京都
    • Year and Date
      2011-09-18
  • [Presentation] End-to-end Flow of Data and Information Sharing within and across Healthcare Providers2011

    • Author(s)
      Naoki Nakashima
    • Organizer
      2nd Annual Mobile Health Asia Summit
    • Place of Presentation
      Singapore
    • Year and Date
      2011-08-23
  • [Presentation] 「シームレスな地域連携医療の実現」の特色と課題 医療圏や医療分野を越えた連携へ2011

    • Author(s)
      中島直樹
    • Organizer
      第15回日本医療情報学会春季学術大会
    • Place of Presentation
      千葉県幕張
    • Year and Date
      2011-06-17
  • [Presentation] e-Health and Diabetes Mellitus in Japan2010

    • Author(s)
      Naoki Nakashima, Yasuaki Antoku
    • Organizer
      The 4^<th> Asia Telemedicine Symposium
    • Place of Presentation
      Soul, Korea
    • Year and Date
      2010-12-18
  • [Presentation] Remote education using a super-east academic internet : growing demands in Asia-Pacific2010

    • Author(s)
      Shimizu S, Nagai E, Nakamura M, Ueki T, Torata N, Antoku Y, Nakashima N, Okamura K, Tanaka
    • Organizer
      ELSA2010 (Endoscopic and Laparoscopic surgeons of Asia)
    • Place of Presentation
      Hanoi, Vietnum
    • Year and Date
      2010-11-25
  • [Book] Capturing Nursing Interactions from Mobile Sensor Data and In-room Sensors2013

    • Author(s)
      Sozo Inoue, Kosuke Hayashida, Masato Nakamura, Nohara Yasunobu, Naoki Nakashima
    • Total Pages
      280-289
    • Publisher
      Springer-Verlag Berlin Heidelberg LNCS, 8014
  • [Book] Portable Health Clinic : A Pervasive Way to Serve the Unreached Community for Preventive Healthcare2013

    • Author(s)
      Ashir Ahmed, Sozo Inoue, Eiko Kai, Naoki Nakashima, Yasunobu Nohara
    • Total Pages
      265-274
    • Publisher
      Springer-Verlag Berlin Heidelberg, LNCS 8028
  • [Book] エビデンスに基づく脳神経看護ケア関連図2013

    • Author(s)
      百田武司, 森山美知子編集
    • Total Pages
      356
    • Publisher
      中央法規出版
  • [Book] ディジーズマネジメントが医療を変える2011

    • Author(s)
      伊藤雅治、福井次矢、森山美知子
    • Total Pages
      72
    • Publisher
      同人社
  • [Remarks] 疾病管理ナース養成講座 : ホームページ

    • URL

      http://dm-nurse.com/

  • [Remarks] 広島大学成人看護開発学 ホームページ

    • URL

      http://home.hiroshima-u.ac.jp/seijin/chronic.html

  • [Remarks] 株式会社DPP ヘルスパートナーズ(本研究の実用化) ホームページ

    • URL

      http://dpphp.jp/

  • [Remarks] 合同会社カルナヘルスサポート ホームページ

    • URL

      http://www.carnahs.co.jp/

  • [Remarks] 1. 日本経済新聞(2013年5月24日)「糖尿病の重病化防ぐ 広島大学研究基に健康指導」 新聞記事

  • [Remarks] 2. 朝日新聞(2013年5月18日)「企業発『重病化防げ』食事・運動療法 自治体など採用」 新聞記事

  • [Remarks] 3. 日本経済新聞, 朝日新聞, 毎日新聞, 読売新聞, 中国新聞(2010年12月15日)「慢性疾患の患者支援」他 新聞記事

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Published: 2015-06-25  

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