• Development and Implementation of The Data Health Plan and Population Health Management
• Chronic Care Nursing : Development of Disease Management Programs, Educational kit, and Measurements and Scales
• Advanced Practice Nursing & Advanced case management
• Development of Chronic Care Professional (CCP) competency-based program
• Advance Care Planning
• Medical Services Delivery System & Outcome Management
• Primary Care
• Family Nursing

• Population Health Management is an approach that uses data to identify the targeted population who are predicted to spend the high future medical care costs and individuals most likely to benefit from care management interventions, to stratify the population from wellness / disease prevention to case management, and provide cost-effective, high quality care (American College of Healthcare Executives, Population Health Alliance). Service programs are offered in response to risk stratification. We are developing the cares and service programs which are accordance with the risk population, including health promotion, disease prevention to end-of life care and palliative care. Based on the development, we conduct experiments in/at communities and businesses (industrial health) to be applied.
• To implement the above, we analyze health indicators, plan the policy based on them, implement and evaluate them.
• To formulate the consistent health management support program, ranging from health promotion to prevention of disease aggravation. (support of health management)

（URL: Chronic Disease Management Project Research Center）
http://home.hiroshima-u.ac.jp/dmcenter/

○ Currently working on

• Development of a self-management program for chronic diseases, focusing on sleep disorders, and measuring the efficacy
• Feasibility and efficacy of a remote monitoring (telenursing) disease management program for preventing diabetic nephropathy aggravation
• Effects of disease management programs for the prevention of recurrent ischemic stroke
• Effects of disease management programs for the prevention of re-hospitalization of heart failure
• Others,

In order to contribute to the establishment of sustainable social security system, we are challenging to develop the Advanced Care Management Model, in which we experimentally place advanced care managers who provide advanced care management in the integrated community care system, from the perspective of the municipal government (medical and care insurers), and support the decision-making including end-of-life care of patients and the families, coordinate care services, and provide disease management education. Through this model, we believe that QOL of patients and the families will be enhanced; and medical costs will be reduced.

Related topics are;

• Research studies on identifying competencies for advanced case management on CKD patients
• Research studies on formulation of a system to identify patients who need advanced case management in communities

Development of the educational program to enhance necessary competency to be engaged in disease management, behavior modification and case management..

• Research studies on development of end-of-life care skills at home for severe chronic diseases and structuring a community medical and nursing care delivery system to accomplish this
• Research studies on promotion of the Advance Care Planning in the community

• Research studies on Accountable Care Organizations, medical service delivery and payment systems
• Research studies on analysis and reconstructing a process for improvement of outcomes such as hip fracture

• Research studies on primary care around the world (for example. roles, functions and education of nurses)
• A project of fostering primary care nurses

Research studies on nursing care for families of the patients with chronic illnesses