进一步强化社区慢性病管理和合理使用有限医保费用的对策  

Chronic diseases management in community and rational use of health insurance cost

作　　者：王琰芳 顾健 周峰 李晓波 仇华 朱小花 徐丽丽 李华 

机构地区：[1]扬州大学临床医学院,江苏省苏北人民医院血液科,江苏省扬州市225001 [2]扬州市广陵区卫生局 [3]扬州大学临床医学院,江苏省苏北人民医院神经内科,江苏省扬州市225001 [4]扬州大学临床医学院,江苏省苏北人民医院预防保健处,江苏省扬州市225001 [5]扬州市广陵区琼花观社区

出　　处：《中华全科医学》2015年第3期415-417,共3页Chinese Journal of General Practice

基　　金：江苏省科技厅支撑计划项目(BZ2009653);江苏省扬州市科技攻关项目(YZ2008031)

摘　　要：通过建立扬州市琼花观社区55岁以上老年慢性病患者的个人健康档案,逐步尝试与大型综合性医院联网,并且建立网络信息平台,从而实现个人健康信息的共享。同时通过分析个人健康档案,明确本社区老年人不同的健康状态和需求,有针对性地开展社区健康教育,提高居民防未病意识,有利于加强慢性病的防治。通过制定完整的双向转诊流程及规范,建立社区-医院间的双向转诊模式,将有效分流患者,缓解大中型医院医疗压力,进一步促进社区卫生的持续发展。通过加强对社区全科医生的培养,提高社区医生对慢性病的管理水平,有利于提高社区卫生服务中心的服务质量,对有序管理社区老年慢性病,降低病死率,控制致残率有一定的作用。课题通过研究扬州市慢性病的医保报销政策,并到社区医院实地观察,发现现有医保政策存在支付范围有限、报销制度单一、取药数量有限等不足,对此提出相关的改进措施,进一步完善了社区慢性病医保费用的报销制度,指导并合理使用有限的医疗费用,使医疗保险更加倾向于社区卫生服务,优化医疗资源的配置。We established the personal health records of elderly patients with chronic diseases over the age of 55 in Qiong- HuaGuan community of Yangzhou. Then we gradually connected to internet with large comprehensive hospital, established network information platform to share personal health information. We analyzed the personal health records to know elderly health status and needs. Then we targeted to carry out community health education to improve the prevention consciousness of the residents, so as to strengthen the prevention and control of chronic diseases. We made a complete two-way referral process and specification, built the mode of two-way referral between community-hospital to bypass patients effectively. It will alleviate the pressure of large hospitals, and promote the sustainable development of community health. We strengthen cultivation of general practitioners of the community to raise the level of their management of chronic diseases. It helped improve the service quality of community health service centers, orderly manage the community chronic diseases of elderly to reduce mortality and disability rate. We studied the reimbursement policy and observed its working, discovered some de- fects such as small paylimits, single reimbursement system, taking little medicine. Then, we put forward the relevant im- provement measures to perfect the reimbursement system of health care costs for community chronic diseases, and guide the rational use of limited health care costs. It made health insurance more inclined to community health service and opti- mized medical resources allocation.

关 键 词：社区卫生服务 慢性病管理 医保费用 

分 类 号：R197.32[医药卫生—卫生事业管理]