四位一体中医慢性病管理模式的构建与应用  

Construction and application of the traditional Chinese medicine four-in-one chronic disease management model

作　　者：王娴[1] 张洁[2] 黄铮[1] 王燕[1] 张芸[2] 周盼盼 顾飞 喻金枝 李梦 祝莹莹 WANG Xian;ZHANG Jie;HUANG Zheng;WANG Yan;ZHANG Yun;ZHOU Panpan;GU Fei;YU Jinzhi;LI Meng;ZHU Yingying(Department of Nursing,Shanghai Municipal Hospital of Chinese Traditional Medicine,Shanghai University of Traditional Chinese Medicine,Shanghai,200071,China)

机构地区：[1]上海中医药大学附属市中医医院护理部,上海市200071 [2]上海中医药大学附属市中医医院中医特色诊疗中心,上海市200071 [3]上海中医药大学护理学院 [4]甘肃中医药大学护理学院

出　　处：《中国护理管理》2024年第11期1608-1612,共5页Chinese Nursing Management

基　　金：上海医学创新发展基金会未来计划(WL-HLZD-2021001k,WL-HLTS-2022001k);上海市卫生健康标准预研制项目(2023WB11)。

摘　　要：目的:构建以治未病理论为指导的“预防-治疗-康复-养生”四位一体中医慢性病管理模式,为中医非药物疗法的推广提供借鉴。方法:建设中医非药物疗法特色诊疗中心,开发中医慢性病诊疗信息管理平台,制定标准化的中医非药物疗法方案,构建中医非药物疗法慢性病管理模式。采用“线上+线下”互动和“门诊+住院”联动方式实施,采取集中式辅以卫星式管理模式。结果:患者整体就医满意度为97.63%,门诊患者人数逐年增长,至2023年服务人次年均64万,建立慢性病患者健康档案178456份。结论:“预防-治疗-康复-养生”四位一体的中医慢性病管理模式可为患者提供全面且个性化医疗服务,改善患者就医体验,提升患者满意率。Objective:To construct the traditional Chinese medicine four-in-one chronic disease management model of"prevention and treatment"guided by the theory of preventive treatment,so as to provide a referece for the promotion of traditional Chinese medicine non-pharmacological therapy.Methods:We built a characteristic diagnosis and treatment center for non-pharmacological therapy of traditional Chinese medicine,developed an information management platform for the diagnosis and treatment of chronic diseases of traditional Chinese medicine,formulated standardized plans on chronic diseases of non-pharmacological therapy of traditional Chinese medicine,and constructed a model for chronic diseases management of traditional Chinese medicine.The model was implemented by"online+offline"interaction and a"clinic+inpatient"linkage network,as well as the centralized management mode supplemented by satellite mode.Results:The patient's medical treatment satisfaction rate was 97.63%.The number of outpatient receptions increased year by year.By 2023,the service volume reached an average of 640000 person-times per year,and 178456 health records of patients with chronic diseases were established.Conclusion:The four-in-one traditional Chinese medicine chronic disease management model of"prevention and rehabilitation"provides patients with comprehensive and personalized medical services,improves patients'medical experience,and enhances patients'satisfaction rate.

关 键 词：慢性疾病 症状管理 中医非药物疗法 

分 类 号：R47[医药卫生—护理学] R197[医药卫生—临床医学]