基于社区慢性病健康管理支持中心的共病管理探索与实践  

Practice of comorbidity management based on community chronic disease health management support centers:an introduction and discussion

作　　者：隋梦芸 张晟 王玉恒[1] 严青华[1] 吴菲 付晨 程旻娜[1] 施燕[1] SUI Mengyun;ZHANG Sheng;WANG Yuheng;YAN Qinghua;WU Fei;FU Chen;CHENG Minna;SHI Yan(Shanghai Municipal Center for Disease Control and Prevention,Shanghai 200336,China;School of Public Health,Fudan University,Shanghai 200030,China;Shanghai Municipal Health Commission,Shanghai 200120)

机构地区：[1]上海市疾病预防控制中心,上海200336 [2]复旦大学公共卫生学院,上海200030 [3]上海市卫生健康委员会,上海200120

出　　处：《中国公共卫生》2024年第10期1284-1288,共5页Chinese Journal of Public Health

基　　金：上海市加强公共卫生体系建设3年行动计划(2023—2025年)(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(GWVI–11.1–22);基于PCIC理论的上海市社区慢性病医防融合的障碍、实施路径与融合机制研究(2024PH61)。

摘　　要：本研究旨在从实践层面深入阐述上海市共病管理具体做法与经验,为长三角乃至全国其他地区共病管理提供参考依据。上海市构建的“诊前风险评估与识别+标签式分类,诊中规范化监测+数据共享整合+多学科协作+辅助性决策,诊后并发症筛查+智能化随访+患者自主管理+标准化健教+新一轮评估”一套完整且闭环的慢性病健康管理服务体系,为慢性病共病患者提供连续性医疗服务。未来慢性病共病管理的潜在方向和路径包括优化多方协作的社会共治机制,进一步完善社区和社会资源供给网络;优化慢性病患者转诊标准和机制;制定医患共同决策以及动态、持续和个性化护理方案;建立基层医疗机构共病患者的多学科协作机制等。This study aims to elucidate the practical approaches and experiences of comorbidity management in Shanghai city,providing a reference for the Yangtze River Delta and other regions in China.Shanghai city has developed a comprehensive and closed-loop chronic disease health management system,which includes pre-diagnosis risk assessment and identification with tagged classification,intra-diagnosis standardized monitoring,data sharing integration,multidisciplinary collaboration,decision support,and post-diagnosis complication screening,intelligent follow-up,patient self-management,standardized health education,and re-evaluation.This system provides continuous medical care for patients with chronic comorbidities.Future potential directions and pathways for chronic comorbidity management include optimizing the social collaborative governance mechanism,further improving the network of community and social resource provision,refining the standards and mechanisms for referral of chronic disease patients,formulating shared decision-making and dynamic,continuous,and personalized care plans,and establishing a multidisciplinary collaboration mechanism for comorbidity patients in primary healthcare institutions.

关 键 词：社区卫生服务 共病管理 支持中心 实践经验 

分 类 号：R197.1[医药卫生—卫生事业管理]