摘要
目的探索将基层慢病管理流程进行优化,建立新型优质高效的慢病管理模式。方法在国内开创性组建由"卫生行政部门/省市区疾病预防控制中心+中心性综合医院+社区卫生服务中心"三位一体构成的专病防治区域医疗联合体,成功运用新模式对南京市鼓楼区所辖全部19个社区居民进行慢病管理。结果截至2018年9月20日,在线管理社区糖尿病病人10 697人,总随访97 097人次,2018年人均随访次数1.23次。纳入管理的糖尿病病人血糖达标率(治疗控制率)为62.7%,高于全国平均水平49%。在线管理社区高血压病人约7892人,血压控制率(治疗控制率)为73%,高于全国平均控制水平38%。结论通过制定和实施高效、优质、科学的基层慢病管理新模式,实现病人预约、追踪随访、数据上传、数据提取、数据监控,通过完全电子化管理极大提高了社区糖尿病管理效率,从而有效提高社区慢病管理水平,提升基层医务人员管理信心,增加慢病病人对基层医院的信任,并最终提高社区居民的生活质量。
Objective To explore the optimization of the chronic disease management processes at grass-roots unit,and to establish a new type of chronic disease management mode with high quality.Methods A regional medical consortium for the prevention and treatment of special diseases was set up by the trinity of "health administration department/CDC + tertiary general hospital + community health service center ".The new model was successfully used to manage chronic diseases in all the 19 communities in gulou district of Nanjing.Results As of September 20,2018,10,697 patients with diabetes in the community were managed online,with a total follow-up of 97,097 times and an average follow-up rate of 1.23 times per people in 2018.The blood glucose compliance rate(treatment control rate) of the enrolled diabetic patients was 62.7%,compared with 49% of the national average level.Atotal of 7892 hypertensive patients were managed online,and the blood pressure control rate(treatment control rate) was 73%,compared with 38% of the national average level.Conclusions Relying on the remote monitoring and remote diagnosis system,specialized doctors in the hospital timely give community doctors guidance on diagnosis and treatment or make referral according to the condition,which improves the diagnostic ability of community hospitals.
作者
王惠
庄永忠
王福影
顾刘宝
娄青林
巫海娣
杨俊
WANG Hui;ZHUANG Yong-zhong;WANG Fu-ying;GU Liu-bao;LOU Qing-lin;WU Hai-di;YANG Jun(Department of Medical Affairs;Department of Endocrinology,Geriatric Hospital of Nanjing Medical University,Nanjing 210024,China;Nanjing Gulou District Commission of Health,Nanjing 210011,China)
出处
《实用老年医学》
CAS
2019年第12期1245-1248,共4页
Practical Geriatrics
基金
江苏现代医院管理研究中心(JSY-2-2017-074)
关键词
慢病管理专科联盟
医疗联合体
分级诊疗
糖尿病
speciality alliance for chronic disease management
medical consortium
graded diagnosis and treatment
diabetes
