Objective To elucidate the construction model of the grassroots chronic disease management center in Tianjin and examine the outcomes achieved following the implementation of the chronic disease management service model,aiming to provide recommendations for its further improvement.Methods Among the 16 districts/counties in Tianjin,one district each was selected from the central areas,near suburbs,and far suburbs as the sampling district.The process and performance indicators including follow-up and standardized management of diabetic patients at grassroots chronic disease management centers in these districts from January to December 2023 were statistically analyzed.Results A total of 47 grassroots chronic disease management centers were operated,at which over 81,000 diabetic patients were followed up,for whom 88,000 health management prescriptions were issued and 68,000 diabetes complication screenings were conducted.There was an average reduction of 10.54%in the referral rate of contracted diabetic patients.The standardized management rate,glycosylated hemoglobin detection rate,blood lipid detection rate,and complication screening rate were raised.Specifically,the complication screening rate exceeded 90%in all three districts.Health outcome indicators,including glycemic control rate,glycosylated hemoglobin compliance rate,blood pressure and blood lipid compliance rates,have been progressively improved.Conclusion Grassroots chronic disease management centers play a role in enhancing the capacity of grassroots medical services and advancing the integration of medical care with preventive efforts.In the future,it is essential to advance the homogeneous management,train chronic disease management teams,foster the motivation of medical,and introduce innovative incentive mechanisms,thus propelling the continued advancement and optimization of chronic disease management centers.
关键词
慢病管理/医防融合/健康管理/糖尿病/天津市
Key words
Chronic disease management/Integration of medical care with preventive efforts/Health management/Diabetes/Tianjin
维普
万方数据