应用德尔菲法构建居家养老冠心病患者健康管理模式的研究

Study on application of Delphi to construction of the health management mode for home-based patients with coronary disease

目的:应用德尔菲法构建居家养老冠心病患者的健康管理模式。方法:选择15名社区护理专家、冠心病专科医生、冠心病专病护理专家和二、三级护理管理专家为函询对象,应用德尔菲法对居家养老冠心病患者的健康管理模式进行2轮函询。结果:专家的权威程度系数为0.86,专家意见协调系数为0.18~0.35;建立的居家养老冠心病患者的健康管理模式包括:建立冠心病居家养老健康管理小组(包括全科医师、家庭护士和健康管理师)、社区卫生服务中心和二、三级综合性医院3个一级管理指标和6个二级管理指标:冠心病居家养老健康管理小组负责上门服务,随访管理,直接实施治疗和护理工作,建立居民健康档案;社区卫生服务中心负责对有关心血管疾病病例进行登记和报告,落实健康咨询、健康教育和健康促进工作;二、三级综合医院负责对辖区内对接的社区卫生服务中心和冠心病居家养老健康管理小组进行技术指导和培训,以及落实远程医疗、远程咨询等指导工作。结论:应用德尔菲法构建居家养老冠心病患者健康管理模式,有利于冠心病的三级预防,可提高冠心病的管理效果,减轻患者医疗费用,节约卫生资源。

Objective: To apply the Delphi to construct the health management mode for home-based patients with coronary disease. Method: Fifteen community nursing experts, coronary heart disease specialists, nursing experts and secondary and tertiary care management experts were chosen as the letter consultation objects. Delphi was used for two times to investigate the health management mode for home-based patients with coronary disease. Result: The authority degree coefficient of the experts was 0.86 and their opinions coordination coefficient 0.18~0.35. The health management mode for home-based patients with coronary disease includes establishing the health management group (general practitioners, family nurses and health administrators), community health service centers, secondary and tertiary general hospitals, three first grade management indicators and six secondary management indicators. The health management group for home-based patients with coronary disease is responsible for onsite service, follow-up management, directly providing medical service and nursing and establishing residents’ health files. The community health service centers are responsible for registering and reporting the cases of cardiovascular diseases, providing health consultation, health education and health promotion. The secondary and tertiary hospitals are responsible for technical guidance and training for the community health service centers and the health management group for home-based patients with coronary disease, providing the telemedicine, remote consultation and other technical guidance. Conclusion: The health management mode for home-based patients with coronary disease is beneficial to tertiary prevention of coronary heart disease, can improve its management effect, mitigate the patients’ medical expense and conserve resources.