城市社区常见慢性病综合防治模式探索

Prevention and Control Mode of Common Chronic Diseases in Urban Communities

本文探讨了运用疾病管理策略开展城市社区慢性病综合防治。通过构建慢性病管理指导网络,组建可持续发展的慢性病管理队伍并进行系统培训,集成社区慢性病防治干预技术及医疗卫生保健技术;通过建立城市社区慢性病信息系统、实行分级诊疗和双向转诊、建立科学的评价体系等社区慢性病支持性环境建设,以实现社区慢性病综合防治的可持续发展。

In this paper the comprehensive prevention and treatment of chronic diseases in urban community was studied by applying disease control strategy.By building up a chronic disease control and guide network,a sustainably-developing contingent for chronic disease control was established,the medical staffs were given systemic training,and the techniques of intervening and controlling chronic diseases and health care skills in community were integrated.The construction of supportive environment for chronic diseases in community was performed,including set up of the chronic disease information system in urban community,implementation of the graded diagnoses and treatments and two-way referral,and establishment of scientific evaluation system,so that the sustainable development of the urban community-based prevention and treatment of chronic diseases can be realized.