家庭医生责任制下全人群健康管理的运行模式探索与实践

A Model of Whole- population Health Management within Family Doctor System

目的探讨家庭医生责任制下的全人群健康管理运行模式。方法自2011年开始,金山区张堰社区卫生服务中心作为金山区家庭医生制服务的试点单位推行家庭医生责任制服务模式。通过强化宣教、扩大覆盖率、完善慢性病自我管理、推行健康一体机等具体措施,开展家庭医生责任制服务。结果 2012年度,张堰社区居民家庭医生签约率为78.5%,健康档案建档率为92.7%,居民健康素养核心信息的知晓率为70.1%,社区居民满意度为98.8%,均高于金山区的平均水平,差异均有统计学意义(P<0.05)。结论张堰社区卫生服务中心家庭医生责任制下的全人群健康管理运行模式卓有成效,在促进居民健康方面发挥了重要作用。

Objective Since the beginning of 2011, a family doctor - based so - called＂ service regionalized, team cooperation - enforced, and responsibility - individualized＂ community healthcare system has been implemented as a pilot experiment in Zhangyan community health service center in Jinshan district of Shanghai. This study aimed to evaluate the whole - population health management under this this test system. Methods Data on various variables measuring the whole - population management were collected and analyzed. Results In 2012, 78.5% of residents in the experimental area signed a health service contract with family doctors in the Zhangyan community health service center, and health records of 92.7% of the residents were electronically archived. More than two third （70. 1 % ） of the residents were aware of the core health literacy information. The overall satisfaction rate in the community residents was substantially high （98.8%） . Conclusion Family doctor - based service system is a trend of the future development of community health services, which is capable of better protecting community residents and improving public service capacity.