社区脑卒中患者“家庭医生式”服务模式的探索与实践

Exploration and practice of “family doctor”service mode among stroke patients in communities

目的积极探索方庄社区脑卒中患者"家庭医生式"服务模式并进行实践。方法从2012年建立的方庄社区脑卒中患者数据库中抽取脑卒中患者77例作为研究对象,采用问卷调查方法对研究对象进行社区卫生需求调查,采用世界卫生组织生活质量量表简表对研究对象进行健康状况测评,按需求调查及健康状况测评结果组建家庭医生式服务团队,开展家庭医生式服务,团队工作实行绩效考核。定期进行专家论证,修正服务体系。积极探索家庭医生式服务模式。结果完成了方庄社区77例脑卒中患者健康状况评价及需求调查,研究对象中,男性40名(51.95%),女性37名(48.05%),平均年龄(70.74±9.56)岁,平均患病时间(9.73±7.20)年。卫生需求主要集中在医务人员出诊服务(占74.0%)、康复指导(占70.1%)、健康教育(占66.2%)、转诊(占58.4%)、医疗器械及药品需求(53.2%)、心理疏导(40.2%)等方面;"家庭医生式"团队服务,一定程度上满足了研究对象的卫生服务需求,其在生存质量主观感觉,健康状况主观感觉、生理领域、心理领域、社会关系领域、环境领域的平均得分均高于干预前;建立和完善了方庄社区脑卒中患者健康评价体系,形成了适合社区脑卒中患者的个性化"家庭医生式"服务模式,并在实践过程中探讨了该模式的有效性及可推广性。结论通过社区脑卒中患者"家庭医生式"服务模式的探索与实践,提高了脑卒中患者的生存质量,提升了社区卫生服务中心脑卒中病管理水平。

Objective To explore and practice the family physicians group patterns among the stroke patients in communi- ty. Methods Total 77 patients with stroke were chosen for the study in established strokedatabase in Fangzhuang commu- nity ; A questionnaire survey methods was used for the study on community health needs ; World Health Organization Quali- ty of Life BREF was used for the study on subjects health status evaluation ; According to the results, a family physicians group was set up to carry out the family doctor services. The performance appraisal was implemented in the team. The service system was corrected by the regular expert discussion. Results Health and Needs Assessment were completed 77 stroke patients in Fangzhuang Community. For research subjects,40 males（51.95% ） ,female 37（48.05% ） ,with an av- erage age of 70.74 ＋ 9.56 years, and mean disease duration was 9.73 -＋ 7.20 years. The health needs was focused on call service （74.0%）, rehabilitation guidance （70.1% ）, health education （ accounting for 66.2% ）, referral （ 58.4% ）, medi- cal equipment and medical needs（53.2% ） ,psychological counseling（40.2% ） and other aspects;The family physicians group patterns had met the demand for health services at a certain level, which in the field of physiology, psychology, the quality of life of social relations, subjective feeling, health, subjective feeling, the average score was higher than the envi- ronmental field before intervention. A needs survey for stroke patients was completed in Fangzhuang community, communi- ty health assessment system of stroke patients was established and improved, a suitable stroke community service model of family doctor style team was formed. Conclusion The family physicians group patterns among the stroke patients in com- munity can improve the quality of life of stroke patients, and the management level of community health service centers.