家庭医生制模式下老年人健康管理方法的实践

Practice of Elderly Health Management Method under Family Doctor Duty System Model

目的探讨深圳市福田区家庭医生制模式下老年人健康管理方法的可行性和有效性。方法对福田区30家已推行家庭医生制的社康中心近1年开展老年人健康管理的做法进行分析,并比较实施前后的效果。结果福田区制定并落实了全科服务团队各成员在老年人健康管理中的岗位职责和服务流程,建立绩效考核办法,实施1年后老年人慢性病规范管理率、服药依从性、满意度、健康体检率和全科诊疗利用率均较实施前明显升高,差异有统计学意义(P<0.05)。结论以家庭医生为核心、全科服务团队参与的老年人健康管理方法具有可操作性、实用性和有效性。

Objective To study the feasibility and effectiveness of elderly health management method in Shenzhen. Methods Analyzing the practice of elderly health management in 30 community health service centers. Results The job duty of each member on general practice team was established. After one year,implementation effect was remarkable（ P 〈0.05 ） ,the rate of chronic disease management, paitent satisfication, the rate of health examination and general practice was better than before. Conclusion This elderly health management method was proved to be practical and effective.