专科延伸服务包——医共体模式下全专结合的健康管理实践  

Specialist extension service package:health management practice of integrating general practice and specialist under medical community mode

作　　者：董寅 李娜 张高峰 Dong Yin;Li Na;Zhang Gaofeng(Health Community Group of the People’s Hospital of Yuhuan,Yuhuan,Zhejiang 317600,China)

机构地区：[1]玉环市人民医院健共体集团,浙江玉环317600

出　　处：《中国公共卫生管理》2025年第1期151-154,共4页Chinese Journal of Public Health Management

基　　金：北京康盟慈善基金会项目(2023XY-WSJK201);台州市科学技术局2024年台州市科技计划项目暨“十链百题”攻关项目(24ywb170);国家卫生健康委医院管理研究所2024年度“医疗质量(循证)管理研究项目”(YLZLXZ24G126)。

摘　　要：随着医共体建设进程的推进,全科与专科结合(以下简称全专结合)的研究与探索在国内广泛开展,但仍存在结合形式不紧密、健康服务不连续的问题。在过渡护理的国内外实践的基础上,玉环市人民医院健共体集团创新推出专科延伸服务包做法,以专病全程管理为切入点,推动总院专科团队与分院全科团队结合,为患者提供连续性健康管理服务。介绍服务包的设计理念、设计思路、运行保障及工作开展成效,对下一步工作进行分析讨论,以期为各地开展全专结合的健康管理工作提供经验借鉴。With the advancement of the construction of medical communities,research and exploration on the integration of general practice and specialist has been widely carried out in China,but problems of loose integration and discontinuous health services still exist.Based on the practice of transitional care domestic and abroad,the Health Community Group of the People’s Hospital of Yuhuan has innovatively launched a specialist extension service package,taking the full-process management of diseases as the entry point to promote the integration of the specialist team from the main hospital and the general practitioners of township health centers so as to provide continuous health services for patients.It introduces the design concept,design ideas,operational support and productive results of the practice,and finally discusses how to further deepen this work in order to provide insights for medical communities to carry out the health management integrating general practice and specialist.

关 键 词：全专结合 延伸服务 健康管理 医共体建设 

分 类 号：R197.1[医药卫生—卫生事业管理]