基于ICCC框架的社区卫生服务机构慢性病管理研究

The chronic disease management in community health service institutions based on Innovative Care for the Chronic Conditions Framework

目的:以世界卫生组织提出的慢性病创新照护框架(Innovative Care for Chronic Conditions Framework,ICCC)为理论基础,从社区卫生服务机构角度出发,分析慢性病管理相关要素的实现现状。方法:采取目的抽样,选取北京市、上海市、郑州市、成都市共12家社区卫生服务中心进行现场调查。采用主题框架法,围绕ICCC框架提出的宏观—中观—微观三层面的关键要素展开分析。结果:基于ICCC框架,从社区卫生服务机构角度来看,以卫生保健组织为代表的中观层面要素功能发挥较好,宏观和微观层面要素缺乏。结论:基于ICCC框架,慢性病管理需在宏观层面加强与卫生系统外相关部门的协作及相关立法;中观层面需加强社区资源或社区支持者的筹集和协调资源能力;微观层面需提高患者(及家庭)的慢性病自我管理能力。

Objective ： To study the chronic disease management＇s key factors in community health service insti- tution based on the Innovative Care for Chronic Conditions Framework （ICCC）. Methods： The purposive sampling method was adopted. Twelve community health service centers were selected as the field survey sites in Beijing, Shanghai, Zhengzhou and Chengdu. During the key factors description at macro-, meso- and micro- level in the IC- CC framework, thematic framework analysis was used to describe the key factors at maro-, meso- and micro level in the ICCC framework. Results： From the community health institutions＇ perspective, the key factors at meso level in the ICCC framework played a better role in the management of chronic conditions while the key factors in both macro and micro level still lacked. Conclusion ： Based on the ICCC framework, the management of chronic diseases needs to emphasize the cooperation with relevant departments outside the health area and legislative strategies at macro level, the ability of community supporters to mobilize and coordinate resources at meso level and the improvement of self- management skills for the patients with chronic diseases.