医院-社区-患者-志愿者一体化慢病管理新模式的构建研究  

Construction of A Hospital-community-patient-volunteer Integrated Chronic Disease Management Model

作　　者：高圆圆[1] 谢波[1] 孙子林[1,2] 荚敏[1] 叶秀利[1] 胡越兰[1] 涂壹长[1] 张福侠[1] 胥新平[1] 杨旎[1] 沈肖[1] 

机构地区：[1]东南大学医学院,江苏省南京市210009 [2]东南大学附属中大医院内分泌科

出　　处：《中国全科医学》2013年第22期2624-2626,共3页Chinese General Practice

基　　金：江苏省科技厅自然科学基金重点项目(BK2010087);江苏省教育科学十一·五规划课题;国家大学生创新实验项目(1310286092)

摘　　要：目的构建医院-社区-患者-志愿者一体化慢病管理新模式,并初步评价其效果和可行性,为制定慢病防控对策提供依据。方法建立以社区为基本结构单元、以患者同伴支持互助小组为主体、以大医院的多学科教育团队为支撑、以志愿者组成的社区慢病管理服务团队为辅助的一体化社区慢病管理网络,并试点实施。通过对社区同伴支持互助小组组长、患者、医护人员、志愿者、卫生管理人员、专家的座谈和深入访谈等方法评价这种模式的初步效果。结果成功构建了医院-社区-患者-志愿者一体化慢病管理模式,该模式能够有效提高患者的依从性、消除患者的孤独感、改善患者的自我管理行为。结论医院-社区-患者-志愿者一体化慢病管理模式是现阶段国情背景下可实现的一种模式,能够有效缓解卫生资源紧缺的矛盾,实现对慢病患者的持续支持,具有可推广价值。Objective To establish a hospital-community-patient-volunteer integrated chronic disease management model and evaluate its efficacy and feasibility.Methods A community-based chronic diseases management network with communities as basic structural units and peer support groups as the main body,supported by multi-disciplinary education teams of general hospitals,and assisted by community chronic diseases management volunteers was established and piloted.The preliminarily effect of this model was evaluated through discussions and in-depth interviews with peer support group leaders,patients,medical staff,volunteers,health management personnel,and experts.Results We have successfully constructed a hospital community-patient-volunteer integrated chronic disease management model.This new model can effectively improve patients＇ compliance,eliminate patients＇ loneliness,and improve their self-management behavior.Conclusion The model is feasible under the current situation.It can achieve sustained support for patients with chronic diseases despite the scarcity of health resources.

关 键 词：慢病 医院 社区 患者 志愿者 管理模式 

分 类 号：R197[医药卫生—卫生事业管理]