医联体-家庭签约及个性化中医养生干预在慢病中的应用效果

Application effect of medical consortium-family contract and personalized traditional Chinese medicine health intervention in chronic diseases

目的探讨医联体-家庭签约及个性化中医养生干预在慢病中的应用效果。方法选取荔湾区2013年11月-2014年11月参加医联体-家庭签约服务慢病管理模式的230例慢病患者作为研究对象,对其健康档案进行统计分析,计算慢病患者的慢病、中医养生知晓率,家庭行为方式改变率及慢病患者用药依从性,比较干预前后的自我管理行为、自我效能、健康状况评分。结果干预6个月后,患者及家庭成员的慢病、中医养生知识知晓率为96.08%,家庭行为改变率为89.56%,服药依从性为73.91%。干预6个月后的自我管理行为、自我效能、健康状况评分显著低于干预前,差异有统计学意义（P〈0.05）。结论医联体-家庭签约及个性化中医养生干预在慢病管理中的效果显著,能够改善患者的健康状况,提高社区慢病的管理与控制。

Objective To explore the application effect of medical consortium-family contract and personalized tradi-tional Chinese medicine health intervention in chronic diseases. Methods 230 cases with chronic diseases participated in chronic disease management mode of the medical consortium-family contract service from November 2013 to Novem-ber 2014 in Liwan district were selected as the research object,the health records of chronic diseases were carried on statistical analysis,the awareness rate of the chronic diseases and traditional Chinese medicine health,the change rate of family behaviour style,the medication compliance of patients with chronic diseases was calculated,the score of self-management behavior,self-efficacy and health status before and after the intervention was compared. Results 6 months later,the awareness rate of the chronic diseases and traditional Chinese medicine health was 96.08%,the change rate of family behaviour style was 89.56%,the medication compliance was 73.91%.The score of self-management behavior,self-efficacy and health status after intervention at 6 months was lower than that before intervention,with significant differ-ence（P〈0.05）. Conclusion The application effect of medical consortium-family contract and personalized traditional Chinese medicine health intervention in chronic diseases management is significant,which can improves the health sta-tus of patients,enhanced management and control of chronic diseases in community.