关键词: 肺癌；患者全程管理；专病管理师；岗位设置

Abstract: Objective: To explore the feasibility and effects of setting up a post of lung cancer specialist disease manager in the management of lung cancer patients. Methods: Through the establishment of a integrated care management center and the specialist disease manager positions, the integrated care management model was implemented for patients with lung cancer. The biopsy screening for malignancy, follow-up compliance rate, diagnosis and treatment completion rate, self-management ability and satisfaction of the enrolled patients were investigated and analyzed. Results: Since the establishment of the post 1 year ago, a total of 5576 patients were enrolled. Among the 186 patients who underwent fiberotic bronchoscopy, the rate of biopsy screening for malignancy was 91.9%, which was significantly higher than the rate before the implementation (35.3%, P<0.001). The follow-up compliance rate in each time period was 100.0%. The medical care service completion rate was 95.3%. Patient self-management score increased from 7.98±2.34 to 9.42±1.63 (P<0.001) and the overall satisfaction rate was 96.3%. Conclusion: The integrated care management model for patients with lung cancer can identify lung nodules early and accurately, assess the lung cancer risk and standardize management of lung cancer treatment, improve patients' self-management ability, and increase patients' satisfaction. The post setting of lung cancer specialist manager provides new ideas for standardizing the management of patients with chronic disease and enriches the connotation of nursing disciplines.

Key words: lung cancer; integrated care management; specialist disease manager; post setting