摘要
本文从签约式家庭医生制、多渠道健康信息、健康危险因素评估、疾病社区综合干预、健康管理效果评价等过程回顾了基于家庭医生制健康管理模式的具体实践。总结了健康管理取得的效果,包括营造了健康管理的工作环境、确立了家庭医生健康管理的新型服务模式、探索了多元化的慢病社区综合防治、开展了高危人群中重点疾病的早发现、构建了生命全周期的健康管理模式。理念转变、支持系统和配套政策、医院社区协作、区域健康档案共享、社区诊断、能力建设是推进社区家庭医生制健康管理的关键所在,同时指出基于家庭医生制的全生命周期健康管理模式是实现新医改提出的人人享有基本医疗卫生服务的理想模式。
Practices of health management based on family doctor system,such as multi-channel health information,health risk factors assessment,community intervention,effect evaluation of health management,obtained in the Songjiang district were reviewed.Effects of health management,including creating healthy working environment,establishing a new service model of family doctors,exploring comprehensive prevention and control of chronic diseases,carrying out early detection of the priority diseases in high-risk groups,building health management model of full life cycle,were summarized.This article argues that five factors of idea changing,supporting systems and policies,hospital community collaboration,regional sharing of health records,community diagnosis,capacity building,is the key to advancing community health management based family doctor system.The article pointed out that the health management of full life cycle based on family doctor system was the ideal model to achieve the policy of universal access to basic health services.
出处
《中华全科医学》
2013年第3期477-478,共2页
Chinese Journal of General Practice
基金
中国社区卫生协会社区卫生科研基金项目(2011-1-6)
关键词
社区卫生服务
家庭医生制
健康管理
Community health service
Family doctor system
Health management
