摘要
在以人为中心的全流程、整合型慢性病人群健康管理理念支持下,基于世界卫生组织整合型慢性病人群管理模式,经过国内相关领域专家反复论证后,作者设计了慢性病人群健康管理服务规范,包括疑似遴选、临床确诊、健康评估、干预方案制定、干预方案实施、随访/随诊、健康再评估7个关键环节,同时设计了专业团队构建、筹资、补偿、激励等支撑体系和机制。旨在通过标准化的服务技术和科学的管理理念,整合区域卫生资源,提升我国慢性病人群健康管理的效率和质量,实现提升居民健康水平的目标。
This article introduces the health management service specification for a chronic patient population.The concept of this specification comes from the whole process of people-centered and integrated health management of the chronic patient population.It is also based on the World Health Organization′s integrated chronic patient population management model.The completion of the specification has gone through several rounds of expert discussion in related fields in China.The contents include seven key links:suspect selection,clinical diagnosis,health assessment,intervention plan development,intervention plan implementation,follow-up,and health reassessment.It also includes establishing a professional team and developing a support system and mechanism of financing,compensation,and incentives.The specification aims at integrating regional health resources through standardizing service technology and scientific management concepts.It would help to improve the efficiency and quality of health management of chronic patient population in China,thereby reducing the economic burden of chronic diseases for patients and their families,and achieving the goal of improving residents′health.
作者
王静
蔡虻
苗艳青
张光鹏
程玉兰
刘国祥
张朝阳
俞鸯
Wang Jing;Cai Meng;Miao Yanqing;Zhang Guangpeng;Cheng Yulan;Liu Guoxiang;Zhang Zhaoyang;Yu Yang(School of Medicine and Health Management,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,China;Department of Disease Prevention and Control,Beijing Hospital,Beijing 100005,China;China National Health Development Research Center,Beijing 100044,China;Chinese Center for Health Education,Beijing 100011,China;School of Public Health,Harbin Medical University,Harbin 150081,China;China Rural Health Association,Beijing 100069,China;Center for Project Supervision and Management,National Health Commission,Beijing 100044,China)
出处
《中华医院管理杂志》
CSCD
北大核心
2020年第6期446-451,共6页
Chinese Journal of Hospital Administration
基金
中国-盖茨基金会农村基本卫生保健项目(OPP1176308)。
关键词
慢性病
健康管理
服务规范
支撑体系
Chronic disease
Health management
Service specification
Support system
