社区慢病药物治疗管理服务模式探索与实践  

Exploration and Practice of A New Service Model of Medication Therapy Management on Community Chronic Disease

作　　者：武明芬 马力[2] 国警月 刘腾[1] 杨莉[1] 赵志刚[1] WU Mingfen;MA Li;GUO Jingyue;LIU Teng;YANG Li;ZHAO Zhigang(Department of Pharmacy,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China;Department of General Practice,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China;Department of Pharmacy,Majiapu Community Health Service Center of Fengtai District,Beijing 100068,China)

机构地区：[1]首都医科大学附属北京天坛医院药学部,北京100070 [2]首都医科大学附属北京天坛医院全科医疗科,北京100070 [3]北京市丰台区马家堡社区卫生服务中心药剂科,北京100068

出　　处：《医药导报》2023年第6期912-917,共6页Herald of Medicine

基　　金：北京药学会2020年临床药学研究项目(2-3-1-847-27);北京药学会临床药学研究项目(LCYC-2022-02)。

摘　　要：目的探索适合我国社区慢病药物治疗管理(MTM)的新模式,提升基层药师慢病药物治疗管理能力,实现对慢病患者的统一连续闭环管理。方法三级医院、二级医院与社区卫生服务中心构建“1+2+3”医联体,药师与全科医师开展多模式协作,通过药师门诊、双向转诊及线上会诊、慢病病例多学科点评、居家药学服务和科普传播等方式开展MTM服务。结果共5个医疗机构(包括1个三级医院,1个二级医院和3个社区卫生服务中心)组建了药学服务医联体,申报并获批了家庭药师培训基地,开展了多种模式的MTM服务。2021年5—12月,双向转诊慢病患者337例,开展慢病点评40余次,识别药物不良反应12例,开展30余户家庭药箱整理,培养家庭药师16名。结论三级联动及医药多模式协作慢病MTM服务模式,能够更好地发挥三级医院的资源及人才优势,提升社区慢病管理能力,实现慢病患者的长期统一连续闭环管理。Objective To explore a new service mode of medication therapy management(MTM)for community chronic diseases in China,improve the ability of MTM services in community pharmacists,and achieve unified continuous closed-loop management for chronic disease patients.Methods A"1+2+3"health alliance was built in Tertiary hospitals,secondary hospitals,and community health service centers.The multi-modal cooperation was carried out between pharmacists and general practitioners.MTM services were performed by the mode of pharmacist clinic,home pharmacy,referral,consultation,multidisciplinary case review,and popular science dissemination.Results A total of five medical institutions(including one tertiary hospital,one secondary hospital,and three community health service centers)were included in the health alliance,the family pharmacist training base was approved,and a variety of MTM services were carried out.From May to December 2021,a total of 337 patients with chronic disease were dual referrals,more than 40 chronic disease review meetings were held,12 cases with adverse drug reactions were identified,more than 30 home medicine cabinets were managed,and 16 family pharmacists were trained.Conclusion The collaboration between different level hospitals,physicians,and pharmacists can better utilize the resources and talent advantages of tertiary hospitals,improve communities’chronic disease management ability,and achieve continuous closed-loop management of chronic disease patients.

关 键 词：药物治疗管理 慢病 服务模式 社区药师 居家药学 

分 类 号：R951[医药卫生—药学]