慢性病的团队式管理、分层早期干预模式在三甲医院中的应用探讨

The study of team management and layered early intervention model for noninfectious chronic disease in third class A Hospital

目的通过构建三甲医院慢性病(NCD)团队管理、分层早期干预模式,提升目标人群参与NCD防控的意愿、提高优质NCD防控的可及性。方法组建NCD管理团队,保障NCD防控的循证性和急救绿色通道的适时序贯启动;建立目标人群自主"拥抱"NCD防控机制,激发其迫切早知晓、早干预、早达标的愿望;实施NCD分层早期管理,提高早知晓、复杂NCD诊疗过程质控和终末达标审计、赢得抢救时间窗的可及性。结果住院患者是逆向序贯驱动NCD防控的激发因素,"内行患者"、NCD管理团队、"智能化医疗程控软件"是实现基于循证的早知晓、早干预、早达标的有效方式。结论该模式是对当前NCD防控体系的良好补充。

Objective To improve the will of the target people participate the prevention and control non-infectious chronic disease（ NCD） and the accessibility of high quality NCD management,the team management and layered early intervention model for the third class hospital should be established. Methods The management team of NCD needed to be established. Thus could the evidence-based of NCD and emergency green channel be ensured; building target population autonomous ＂hug＂NCD mechanism to inspire their will of early know,early intervention and standard; layer early intervention model should be carried out to increase target rate of quality control procedure and final audit for complex NCD diagnosis,to save rescue time. Next,the function that target group would take the NCD initiatively was established. The groups＇ demands to know earlier,intervene earlier and achieve the goal earlier would be encouraged. Results Inpatient was motivator for reverse sequential driving NCD prevention and control,expert patient,team management and＂Intelligent medical SPC software＂were effective models for early know,early intervention and standard. Conclusion This mode is an effective supplement of noninfectious chronic disease management.