심뇌혈관질환 고위험군 등록관리 시범사업과 맞춤형 방문건강관리사업 연계모형 개발

Development of Linkage Model of Registry & Management Service for High Risk Group of Coronary & Cerebral Vessel Disease and Tailored Home Visiting Health Service

Purpose: The purpose of this study is to develop the linkage model of Registry & Management Service for High Risk Group of Coronary & Cerebral Vessel Disease and Tailored Home Visiting Health Service. Method: This model was developed through literature review, survey and expert meetings. The subjects of the survey were 66 service discontinuity clients of Registry & Management Service for High Risk Group of Coronary & Cerebral Vessel Disease and 174 Tailored Home Visiting Health Service on hypertension and DM. Results: The linkage model of Registry & Management Service for High Risk Group of Coronary & Cerebral Vessel Disease and Tailored Home Visiting Health Service was developed based on not integration model but linkage model, not service linkage but client linkage, team case management model, e-partnering, strategic alliance, and linkage support center. Conclusion: This linkage model is considered an effective model to make synergy of two services. Additional researches are needed and to prove the effect of this linkage model.