基于家庭医生模式的深圳市社区慢非传健康管理路径的实践与思考

Practice on the Health Management Path for Chronic Non- infectious Diseases in Shenzhen Based on Family Doctor Service Mode

深圳市采用"家庭医生责任制"进行全科医学服务路径、慢性非传染性疾病(慢非传)社区健康管理路径的探索和试点,在实践中探索出把慢非传等疾病的健康管理融入到全科医生的日常服务中,利用信息化进行智能化的健康管理,利用"高危评估量表"进行高危人群的筛查和管理,采用手机APP和"健康存折"等个性化措施进行服务。实践证明,以家庭医生服务模式进行社区慢性非传染性疾病的健康管理是一种综合、高效、经济的方法,能够充分体现社区卫生服务及全科医学的特点及优势,可为社区慢性非传染性疾病的健康管理提供借鉴。

This article introduces Shenzhen~ exploration and experiment of general Practice Service path and chronic - non - infectious dis- ease health management path in promoting family doctor service plan project. In practice explore the chronic - non - infectious disease health management into General Practitioners （GPs） ~ daily service, the use of software system help to provide intelligent health management, the use of risk - assessment - scale to screen and management for the ehronicnon - infectious disease high risk population. And use of mobile App software and health passbook to have personalized service for the people. The practice that： use of the family doctor service mode and method to chronic - non - infectious disease are the comprehensive, high efficient and economic health management methods. And these can fully reflected the advan- tages and characteristics of Community Health Service. And provide reference for health management of chronic - non - diseases.