Multidisciplinary models of primary health care for patients with chronic non-communicable diseases

Abstract

Introduction. Chronic non-communicable diseases (CNCD) requires a variety of strategies from different perspectives and at different levels, including individual and country-specific. Comprehensive patient-oriented and proactive approaches play an important role in the provision of multidisciplinary teams of medical care to patients with established CNCD. The purpose of this study is to present the Moscow experience in managing multidisciplinary teams for the treatment of CND patients, using the example of arterial hypertension in the framework of a pilot project in the outpatient clinics of the Troitsk and Novomoskovsky administrative districts (TiNAO; were attached to the territory of Moscow in 2012). Materials and methods. The study was conducted in two stages: at the first, a literature review was carried out, at the second, the stages of launching a pilot project on the management of multidisciplinary teams for the treatment patients with CNCD, using the example of arterial hypertension in the outpatient clinic of TinAO, were developed and discussed. Results. The research analyzes approaches to the use of multidisciplinary teams in the world. Based on the analyzed current regulatory documents, adjustments were made to the foreign model for its possible adaptation to Moscow polyclinics, focusing on proactive dispensary dynamic monitoring. Research limitations. The results of the conducted research are based on operational data from Moscow and can be applied only to the formation of management decisions in Moscow. Conclusion. According to the results of the pilot project testing, an increase in the level of coverage of the attached population with medical care, accessibility of narrow specialists and provision of equal opportunities for obtaining medical care for Muscovites was noted.