上海市整合式社区慢性病健康管理模式实践探索  

Exploring the practice of integrated community chronic disease management model in Shanghai

作　　者：程旻娜[1] 隋梦芸 张晟 郑杨[1] 顾凯[1] 杨群娣[1] 阮晔[1] 王玉恒[1] 严青华[1] 杨沁平 付晨 余荣 施燕[1] CHENG Minna;SUI Mengyun;ZHANG Sheng;ZHENG Yang;GU Kai;YANG Qundi;RUAN Ye;WANG Yuheng;YAN Qinghua;YANG Qinping;FU Chen;YU Rong;SHI Yan(Shanghai Municipal Center for Disease Control and Prevention,Shanghai 200336,China;Shanghai Municipal Health Commission,Shanghai 200125,China)

机构地区：[1]上海市疾病预防控制中心,上海200336 [2]上海市卫生健康委员会,上海200125

出　　处：《广西医科大学学报》2024年第10期1370-1373,共4页Journal of Guangxi Medical University

基　　金：上海市加强公共卫生体系建设3年行动计划(2023—2025年)(No.GWVI-8);上海市加强公共卫生体系建设3年行动计划(2023—2025年)公共卫生重点学科建设项目(No.GWVI-11.1-22);上海市卫生健康委员会资助项目(No.2024HP61)。

摘　　要：人口老龄化的加重使得慢性病的防治压力日益凸显且面临前所未有的挑战。上海市政府历来重视慢性病防治工作并取得了良好成效,建立起政府主导、多部门合作、全社会参与的慢性病防治工作机制、“四位一体”的慢性病综合防治模式和市区两级的慢性病健康管理信息系统。近年来,上海市围绕“以健康为中心”的服务策略,构建整合式社区健康管理模式,通过出台慢性病综合防治工作规范、完善慢性病健康管理信息系统和推广慢性病健康管理支持中心,通过技术、数据和服务3个层面开展整合探索,不断完善和优化模式的内涵;模式实施成效显著,整合式社区健康管理模式在全市范围内实施并深入推广,完成健康风险评估217.61万人(其中共病随访服务61.99万人),开展高风险人群发现与管理,服务人数提高了9倍;同时建成72个社区慢性病健康管理支持中心,提供标准化服务390万人次,覆盖81万人,血压、血糖等指标异常检出率较常规提高了10%~20%,具有较好的卫生经济学效益,已被纳入健康上海行动和社区卫生服务能力提升等多项政策并逐步推向长三角地区。未来将持续优化整合式社区慢性病健康管理模式;基于大数据应用,构建线上、线下协同的干预服务;建立评价指标体系,完善慢性病综合防治服务评价。The aggravation of population aging has made the pressure of chronic disease prevention and treatment increasingly prominent and faced unprecedented challenges.The Shanghai Municipal Government has al-ways attached great importance to the prevention and treatment of chronic diseases and has achieved good results,establishing a government-led,multi-sectoral and community-wide mechanism for the prevention and treatment of chronic diseases,a“four-in-one”model for the comprehensive prevention and treatment of chronic diseases,and an urban and municipal-level chronic disease health management information system.In recent years,Shanghai has built an integrated community health management model based on the“health-center”service strategy,continuously improving and optimising the connotation of the model through the introduction of specifications for the comprehensive prevention and treatment of chronic diseases,the improvement of the chronic disease health management information system and the promotion of the construction of chronic disease management center,as well as the exploration of integration at the three levels of technology,data and services.The model has been implemented with remarkable results,and the integrated community health management model has been implemented and deeply promoted throughout the city,completing the health risk assessment of 2,176,100 people(including 619,900 people with co-morbidities follow-up services),carrying out the discovery and management of high-risk population,and increasing the number of people served by a factor of 9 times.At the same time,72 community chronic disease management centers have been built,and standardized services have been provided for 3.9 million times,covering 810,000 individuals.The detection rate of abnormalities in blood pressure,blood glucose and other indicators has increased by 10%to 20%compared with the norm,with better health economics benefits.These centers have been incorporated into many policies such as the Healthy Shanghai Initiative and

关 键 词：整合式 社区 慢性病 健康管理模式 信息化 

分 类 号：R473[医药卫生—护理学]