基于医联体的社区糖尿病全专团队管理模式探索与实践  

Exploring the Empowerment of Chronic Disease Management under the Multi-Party Linkage Mode

作　　者：张梦娇[1] 钱宁 程頲 Zhang Mengjiao;Qian Ning;Cheng Ting(Hongqiao Community Health Service Center of Changning District,Shanghai,200051,China)

机构地区：[1]上海市长宁区虹桥街道社区卫生服务中心,上海200051

出　　处：《中国初级卫生保健》2023年第12期65-67,共3页Chinese Primary Health Care

基　　金：上海市卫生健康委员会基金项目(202040142,ZY2020-2022-JCTS-1001);上海市社区卫生协会基金项目(SWX21Z03);上海市长宁区卫生健康委员会基金项目(20194Y027;20214Y046;RCJD2022S10)。

摘　　要：目前,我国是全世界糖尿病患者人数最多的国家,但患者血糖总体控制率不佳。慢性病管理作为家庭医生签约服务中的重点内容之一,应开展针对性健康教育,加强“体医结合”,提高健康素养,引导居民践行“健康第一责任人”的理念。社区患者由于受到年龄、文化程度等影响,对于时间较短的门诊和季度随访无法达到让其形成健康理念的目的。因此,通过建立由三级医院专家、具有专科能力的全科医生、专科护士、药师组成的糖尿病“全专”团队,以及“全专”门诊、区域医疗联合体、“线下”讲座、“线上”科普、慢性病小组活动、慢性病档案数据分析等联动模式下的赋能管理,使社区患者的糖尿病知晓率、血糖控制率和规范管理率不断提升。China is the country with the largest number of diabetes patients in the world at present,but the overall control rate of patients’blood sugar is poor.As one of the important contents of family doctor’s contracted services,chronic disease manage⁃ment should carry out targeted health education,strengthen the integration of sports and medicine,improve health literacy,and guide residents to practice the concept of“health first responsible person”.Due to the influence of age and educational level,community patients cannot achieve the goal of forming a healthy concept for short-term outpatient and quarterly follow-up.Through the estab⁃lishment of a diabetes specialist team,which is composed of three-level hospital experts,general practitioners with specialized abili⁃ties,specialized nurses,and pharmacists,through the empowerment management under the linkage mode of full specialist outpatient services,regional medical federations,offline lectures,online science popularization,chronic disease group activities,chronic disease file data analysis,the awareness rate,blood glucose control rate,and standardized management rate of patients with diabetes can be improved.

关 键 词：全专结合 慢性病管理 医联体 家庭医生签约服务 

分 类 号：R197[医药卫生—卫生事业管理]