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"要旨：北信州地域は高齢化率が高く、独居の高齢者世帯も多い。慢性心不全を持った生活者はその増悪により入退院を繰り返すことがある。心不全の経過は、食事・内服管理などの生活面の管理により増悪が左右される。心臓病を持った生活者が安定した在宅生活を維持していく為に、病院とかかりつけ医が連携し治療を行う地域連携パスを、2009 年から運用開始した。更に、多職種が関わる医療連携により生活面から支える仕組みと、介護との連携が課題となり、2012 年に北信州心臓病地域連携包括ケア推進協議会を設立し、2 次医療圏の多職種、多業種が顔の見える関係をもって協働・連携できる地域包括ケアシステム構築に取り組んできた。設立後6 年間の事業経過を報告する。", "subitem_description_type": "Abstract"}]}, "item_6_description_30": {"attribute_name": "資源タイプ（コンテンツの種類）", "attribute_value_mlt": [{"subitem_description": "Article", "subitem_description_type": "Other"}]}, "item_6_description_5": {"attribute_name": "引用", "attribute_value_mlt": [{"subitem_description": "信州公衆衛生雑誌 14(1): 38-39(2019)", "subitem_description_type": "Other"}]}, "item_6_publisher_4": {"attribute_name": "出版者", "attribute_value_mlt": [{"subitem_publisher": "信州公衆衛生学会"}]}, "item_6_select_64": {"attribute_name": "著者版フラグ", "attribute_value_mlt": [{"subitem_select_item": "publisher"}]}, "item_6_source_id_35": {"attribute_name": "ISSN", "attribute_value_mlt": 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