医院-社区-家庭三元联动延续护理平台的设计及应用

Design and application of continuing care service platform under the linkage of hospital-community-family

目的构建医院-社区-家庭三元联动延续护理平台,以进一步提高延续护理效率和效果。方法在医院网页的大框架下,借助网络信息技术搭建延续护理平台,医院、社区、家庭三方之间可实现出院患者信息数据共享、沟通互动,结合患者的实际情况,医院和社区从不同角度给予患者多形式、个性化的干预措施,并通过评价检测平台实用性、便捷性和创新性,检测延续护理服务效果。结果初步构建了包含8个模块的延续护理平台,并在医院内分泌病房试用近半年,数据显示糖尿病出院患者自我管理达标率由原来的51.7%提高到89.1%,2个合作社区与医院间专业帮扶、培训指导、信息共享运行通畅,平台的运行满意度评价较好。结论该平台充分利用了医院医护优质资源、社区基层延伸点、家庭辅助照护的互动,最大限度整合资源,为患者提供延续护理服务。

Objective To build a continuing care service platform based on hospital-community-family communication and interaction to further improve efficiency and effectiveness of continuing care service. Methods Under the framework of hospital web sites,continuing care service platform was established via network information technology. Data sharing and interactive communication of discharged patients were achieved among hospital,community and family. According to patients＇ actual situation,hospital and community provided patients various and personalized interventions. The practical effects of continuing care service was evaluated by practical,convenient and innovative aspects of the platform. Results Eight modules of continuing care service platform were initially established,and tested in department of endocrinology for half year. Data showed that self-management compliance rate of diabetic patients improved from 51.7% to 89.1%. Professional assistance,training guidance and information sharing between community and hospital functioned smoothly. The evaluation results of the platform running were satisfying. Conclusion The continuing care service platform based on hospital-community-family fully took advantage of interaction among high quality resource from the hospital,primary care from the community and auxiliary care from the family. It integrated resources furthest to informationize continuing care service.