摘要
天津市东丽区军粮城医院基于医防融合视角,创新构建了"一体两翼"医防融合型慢性病管理服务模式,旨在提升基层医疗卫生机构在慢性病管理中的效率与质量.该模式依托慢性病管理大团队、3+1+N基础管理团队和专病小组,有效促进了医疗与公共卫生服务的深度融合.结合糖尿病案例研究,预期将显著提升慢性病患者的管理率、控制率和自我管理能力,降低并发症发生率,减轻患者医疗负担,合理利用医保基金,同时提高患者和医务人员的满意度,进而改善患者健康状况和生活质量.但该模式还存在信息化不完善、空间和人员不足、激励政策不足等问题.建议加快信息化平台建设、科学扩展空间、优化管理流程、加强经费保障等.
Abstract
Based on the perspective of the integration of medical and prevention,Junliangcheng hospital of Dongli District,Tianjin City constructs the integrated medical and preventive chronic disease management service model of"one entity with two wings",aiming to enhance the efficiency and quality of chronic disease management in primary medical and health institutions.Relying on the large chronic disease management team,the the 3+1+N basic management team and the special disease group,this model effectively promotes the deep integration of medical and public health services.Based on the case study of diabetes,it will significantly increase the management rate,control rate and self-management ability of patients with chronic diseases,reduce the incidence of complications,alleviate the medical burden of patients,make reasonable use of medical insurance funds,and at the same time improve the satisfaction of patients and medical staff,thereby improving the health status and quality of life of patients.However,issues such as inadequate informatization,insufficient space and staffing,and lack of incentive policies still exist in this model.It is suggested to accelerate the construction of informatization platforms,scientifically expand space,optimize management processes,and strengthen financial support.
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