Empirical Exploration on the Collaboration of General Practice and Speciality in Chronic Disease Management:Taking the"Six Ones"Construction of Community Osteoarthritis Management as an Example
At present,the collaboration of general practice and speciality has been applied to the diagnosis,treatment and management of various chronic diseases in the community based on the technical support of disease diagnosis and treatment and the implementation of hierarchical diagnosis and treatment.Based on the patient-centered,systematic and holistic thinking characteristics of general practice,the general practice team of Yangpu Hospital Affiliated to Tongji University explored and practiced a more comprehensive,in-depth and effective collaboration model of general practice and speciality around the multi-dimensional construction of'six ones'.The construction of'six ones'was based on the collaboration of general practice and speciality between general hospitals and community health service centers.Taking osteoarthritis(OA),a common chronic disease in the community,as an example,its contents and characteristics were as follows.(1)Establishment of a multidisciplinary team:the established team could rely on the basis of the three-dimensional integrated health care system of the general hospitals,to give play to the liaison and coordination role of general practice department in general hospitals,refine and coordinate the multidisciplinary division of labor;(2)Improvement of a set of diagnosis and treatment processes:improve a set of hierarchical diagnosis and treatment process for diseases based on scientific evidence,and evaluate the effectiveness of the diagnosis and treatment process,so that it could help to improve patients'symptoms and quality of life;(3)Development of an APP:the developed APP could cover multiple functions such as hierarchical diagnosis and management of OA patients,doctor-patient communication,popularization of science,appointment registration,and could record the complete diagnosis and treatment data in the exclusive information platform;(4)Designing a set of publicity and promotion programs:Publicize the program in multiple scenarios such as disease diagnosis and treatment,health examination and consultation in general hospitals and communities through a variety of forms of text,pictures and videos;(5)Establishment of a case database:establish a specific disease database for OA patients,continuously follow up patients and implement hierarchical management of the collected data,so as to provide more cases with general characteristics;(6)Construction of a set of curricula:the curriculum is built around OA specialties,including"bone pain as an undifferentiated disease in general practice"and"chronic disease management of OA",the course is conducted in the form of problem-oriented learning,outpatient consultation and teaching round demonstration,which was for multi-level training of undergraduate,graduate and continuing education.Taking the'six ones'construction of OA management in the community as an example,the practice of the collaboration of general practice and speciality for the management of chronic disease based on the thinking of general practice suggests the potential of comprehensive,in-depth cooperation and mutual promotion between the two sides in multiple dimensions of medicine,teaching and research,as well as the effectiveness of optimizing and integrating the team,technology and information support related to hierarchical disease management for promoting the physical and mental health of patients.
General practiceCommunity health servicesClinical thinking of general practiceCollaboration of general practice and specialitySix of ones
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