Unfoldment of a Resident-Participatory Population Health Management in an Aging Community with a Declining Population

2014 Fiscal Year Final Research Report

• Project/Area Number: 24659988
• Research Category: Grant-in-Aid for Challenging Exploratory Research
• Allocation Type: Multi-year Fund
• Research Field: Clinical nursing
• Research Institution: Hiroshima 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): SADAMORI Takuma 広島大学病院, 病院助教 (40437611)
• Project Period (FY): 2012-04-01 – 2015-03-31
• 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

Outline of Final Research Achievements

We conducted action research applying the concept and methodology of Population Health Management in an aging community with a declining population where the medical and long-term care expenditures were increasing. Advanced practice nurses (clinical nurse specialists) analyzed the health indicators of the community, stratified the residents based on their health risks, and planned health strategies with the administrators, medical and caretaking stakeholders in accordance with risk characteristics with a view to entire prevention from the primary to the tertiary.We implemented disease management and disease severity prevention, introducing telemedicine and promotion of advanced care planning. As a result, we observed a significant improvement in the health indicators. The results suggest that this model can contribute to the restoration of medical and long-term care finance and can be a pioneering model of the integrated community care system in Japan.

Free Research Field

慢性病看護学