社区慢性病管理工作相关问题与对策探讨

Chronic disease management in community： challenge and strategy

调查徐家汇社区卫生服务中心下属中心团队与塘子泾团队在社区开展慢性病管理的情况，发现社区全科团队在工作中面临以下问题：①随访工作任务繁重和医务人员相对不足；②社区居民健康理念不科学，对开展慢性病预防管理的重要性认识不足；③慢性病信息管理系统建设滞后，效率不高。针对慢性病管理工作相关问题，对提高社区慢性病管理效果的对策进行探讨。

In a survey on chronic disease management in Xujiahui Community, we found that the general practice team was facing the following problems ： ① Heavy burden of follow-up work by a relatively smaller number of physicians ; ② Misunderstanding of health and insufficient recognition of the importance of chronic disease management among community residents; and ③ Delayed database construction and inefficient performance. In this study, we described the strategies to improve chronic disease management in communities.