我国分级诊疗政策背景下社区慢病管理实践分析  

Analysis of Chronic Disease Management in the Community Under the Background of Hierarchical Medical Policy of China

作　　者：张源 凌涛 范蒋青 兰霖燕 计成 葛卫红[1,4] ZHANG Yuan;LING Tao;FAN Jiangqing;LAN Linyan;JI Cheng;GE Weihong(Department of Pharmacy,China Pharmaceutical University Nanjing Drum Tower Hospital,Nanjing 210008,China;School of Basic Medicine and Clinical Pharmacy,China Pharmaceutical University,Nanjing 210009,China;Department of Pharmacy,Suqian First Hospital,Suqian 223800,China;Department of Pharmacy,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]中国药科大学南京鼓楼医院药学部,南京210008 [2]中国药科大学基础医学与临床药学学院,南京210009 [3]宿迁市第一人民医院药学部,宿迁223800 [4]南京大学医学院附属鼓楼医院药学部,南京210008

出　　处：《医药导报》2023年第11期1691-1696,共6页Herald of Medicine

基　　金：国家自然科学基金资助项目(721044105)。

摘　　要：目的对国内分级诊疗政策背景下社区慢病管理实践现状进行归纳总结,提出改进建议,并探索一种综合社区慢病管理模式,以期为社区慢病管理工作的建设和发展提供参考。方法检索国家医疗保障局、国家卫生健康委员会、中国政府网、国家中医药管理局等官方网站公开的分级诊疗相关政策文件,通过中国知网数据库、维普资讯中文期刊服务平台和万方数据知识服务平台,检索我国社区慢病管理实践,检索时间为2009年1月—2023年4月。结果国家陆续颁布和完善相关文件,推进分级诊疗体系建设。在此背景下,全国各地陆续进行了慢病管理模式的探索和实践,积累了丰富的经验,形成了多种管理模式,均具有上下联动的分级诊疗特点。目前主要的慢病管理模式有医联体模式、家庭医生签约服务模式、“互联网+”模式和基于全科医生的社区健康管理模式。结论分级诊疗背景下,我国社区慢病管理模式多样,全国各地应依托现有医疗平台与机构体系,选择适合本地区的慢病管理模式,积极落实和完善社区慢病管理实践,以提升全国慢病管理水平。Objective To summarize the current situation of chronic disease management in the community under the background of hierarchical medical policy of China,to make suggestions for improvement,to explore a comprehensive chronic disease management model,and to provide a reference for the construction and development of chronic disease management in the community.Methods The policy documents related to hierarchical medical system published by the official websites of the National Healthcare Security Administration,the National Health Commission,the website of the National Council,and the National Administration of Traditional Chinese Medicine were retrieved.The management practices of chronic diseases in the community in China were retrieved through CNKI,VIP,and Wanfang databases from January 2009 to April 2023.Results China has successively promulgated and improved relevant documents to promote the construction of a hierarchical medical system.In this context,the exploration and practice of chronic disease management models have been carried out throughout the country,accumulating rich experience and forming a variety of management models,all of which have the characteristics of graded diagnosis and treatment with linkage up and down.At present,the main chronic disease management models include the medical alliance model,the family doctor contract service model,the"Internet Plus"model,and the community health management model based on general practitioners.Conclusion Under the background of graded diagnosis and treatment,there are various community-based chronic disease management models in China,and all regions in the country should rely on the existing medical platform and institutional system to choose a chronic disease management model suitable for the region and actively implement and improve community-based chronic disease management practices to improve the national level of chronic disease management.

关 键 词：分级诊疗 政策梳理 社区慢病管理 

分 类 号：R95[医药卫生—药学]