强化医院慢病管理服务的实践

Practice on strengthening hospital chronic disease management

医院体检、门诊及住院病人的慢病管理新模式,以医院慢病管理信息化平台为支撑,多学科联合诊治为特点,通过绩效考核手段达到医患双向促进。该模式利用医院专家在疾病检查、诊断治疗、生活方式干预等方面的主导地位及病人对综合性医院信任度高的特点,充分发挥医院优势资源,提供个性化、连续性、优质高效的院内外慢病管理服务,实现慢病诊治、管理一体化,为医院开展慢病管理服务开辟一条新路。

New mode of chronic disease management for healthcare test, outpatient and inpatient can be described as joint management of multi-discipline diagnosis and treatment, hospital chronic disease management information platform and performance management to get the effect of hospital patient harmonious communication. By effectively using excellent health resources in general hospital such as diagnosis, test, treatment, lifestyle intervention and hospital brand, an integrated chronic disease management mode which involves hospital care, other health institute care and family care and provides personal, continuous, good quality and efficiency chronic disease care and management is applied and has got a new way on hospital chronic disease management.