摘要
目的探讨全科-专科团队模式对稳定冠心病患者在社区进行协同管理的作用。方法在医联体框架下组建全科-专科团队,由全科医生首诊、管理,定向精准转诊,然后专科医生从专科的角度提出管理的意见,协同管理,实施冠心病社区团队协同管理规范,总结经验,提高全科医生对冠心病管理的临床水平。结果1例冠心病患者经全科-专科团队模式协同管理2年后,病情稳定,取得了较好的临床疗效和患者满意度,为社区实施冠心病二级预防管理模式提供依据。结论医联体内全科-专科团队协同管理在冠心病的管理方面具有一定的优势,能够提高患者依从性,提高患者生活质量,临床应用价值高。
Objective To explore the effect of general practice-specialist team model on community collaborative management of patients with stable coronary heart disease.Methods In the framework of medical association,a general-specialty team is set up.Patients are diagnosed and managed firstly by general practitioners,with targeted and accurate referrals.Then,the specialists propose management opinions from the perspective of the specialties,conduct collaborative management,implement the standard of community team collaborative management of coronary heart disease,sum up experience and improve the clinical level of general practitioners in the management of coronary heart disease.Results A patient with coronary heart disease was managed by the general practice-specialist team for 2 years,and his condition was stable.Good clinical efficacy and patient satisfaction were achieved.The experience of this case provided a basis for the community to implement the secondary prevention management model for coronary heart disease.Conclusion The cooperative management of general department and specialized department within medical association has certain advantages in the management of coronary heart disease,which can improve patient compliance and quality of life,and it has high clinical application value.
作者
赵继华
赵文淑
赵付英
姜岳
刘玉江
ZHAO Ji-hua;ZHAO Wen-shu;ZHAO Fu-ying;JIANG Yue;LIU Yu-jiang(Department of General Practice,Gaobeidian Community Health Service,Beijing 100024,China;不详)
出处
《慢性病学杂志》
2021年第7期1001-1004,1008,共5页
Chronic Pathematology Journal
基金
社区老年冠心病管理中的药学服务模式研究(首发2018-3-7034)
关键词
冠心病
全科
专科
医联体团队协同
Coronary heart disease
General practice
Specialization
Medical consortium team collaboration
