社区团队服务中脑卒中双向转诊模式的探索与实践

Exploration and Practice of the Two-way Referral Pattern for Stroke in Community Team Health Service

目的探索社区团队服务中脑卒中双向转诊模式。方法以社区脑卒中管理为突破口,积极探索北京市方庄社区卫生服务中心与市卫生局指定的对口支援医院——天坛医院之间实施脑卒中双向转诊模式。结果社区脑卒中有效管理率达到92.7%,失访率下降了20.6%;社区居民卒中知识知晓率达到88.5%。结论通过社区团队服务中脑卒中双向转诊模式的探索与实践,有力的提高了社区卫生服务中心的医疗质量和慢性病管理水平,提升了社区卫生服务工作的内涵。

Objective To explore the two-way referral pattern for stroke in health service of community team. Methods Taking the community stroke management as the core,two-way referral pattern was explored positively between the supporting hospital assigned by the health bureau of the city-Tiantan hospital and Beijing Fangzhuang community health service center. Results Effectively managing rate of stroke in communities reached 92.7 percent,the lost rate of follow-up dropped by 20.6 percent,and awareness rate of knowledge on strok reached 88.5 percent. Conclusion By this way,medical quality of the community health service centers and chronic disease management were improved,the content of community health serviceswas enhanced.