A Holistic, Patient-Centered Care Model

In 2018 the Center became the first in Taiwan to create a holistic care model for rheumatic disease that systematically combines comorbidity evaluation with personalized therapy. Recognizing that patients with chronic inflammatory disease carry elevated risk for cardiovascular events, interstitial lung disease, osteoporosis and fragility fractures, and depression, we built a cross-specialty team that includes pulmonologists, cardiologists, orthopedic surgeons, psychiatrists, dietitians, physical and occupational therapists, respiratory therapists, psychotherapists, and social workers working in concert with our rheumatologists and allergists.

This “three-stage, five-level” prevention framework—health promotion, early detection, targeted treatment, complication control, and functional rehabilitation—was honored with the Symbol of National Quality (SNQ) for “Comorbidity Assessment and Personalized Treatment” (2021–2023). A second SNQ (2022–2024) followed for our diagnostic and treatment program for adult-onset Still's disease, and in 2023 the Center received the National Healthcare Quality Award, designating it a Center of Excellence for clinical standards in Taiwan.

Several systems make this model work in daily practice. Our real-time disease-activity dashboard displays DAS28, BASDAI, PASI, PsA composite scores, and patient-reported outcomes for every patient at the point of care, helping the clinician and the patient pursue treat-to-target therapy together. Our electronic shared decision-making (SDM) platform structures conversations about biologic and JAK-inhibitor selection, with built-in risk assessment and patient education; medication adherence beyond one year now exceeds 96 percent. A risk-management program (RMP) screens for and monitors latent tuberculosis and viral hepatitis in every patient considered for immunosuppression. The PHQ-9 and PDCA cycles are used quarterly to identify and treat depression in our cohort, with referral pathways into psychiatry and psychotherapy. Our cloud-based health education platform, complemented by a smartphone app, extends education and self-management support to patients and their caregivers beyond the clinic walls—a feature that proved particularly valuable during the COVID-19 pandemic.

The Center's “all-in-one-step” service consolidates clinical examination, ultrasonographic assessment, decision-making, and patient education within a single visit, reducing the burden of return appointments and shortening time to therapy. Patient satisfaction has consistently exceeded 90 percent for outpatient and inpatient services, and exceeded 95 percent for patient education programs, since 2018.