脑卒中患者社区管理机制的实践与不足

Practice and Deficiency of Stroke Community Management

脑卒中社区管理已付诸实践,实现了信息汇总和初步的健康教育指导。但信息利用不够充分,人力资源运用不足,居民的健康教育持续性不够,康复应用依从性相对不高,相关考核不利于医师主动参与。建议回到全科医师主导的家庭医师模式中来,使疾病管理落在实处。

Community management of stroke has been put into practice, and information collection and preliminary health education guidance have been achieved. However, the use of information is insufficient, the use of human resources is insufficient, the health education of the residents is not enough, the compliance of the rehabilitation application is relatively low, and the related assessment is not conducive to the active participation of doctors. It is suggested that we should go back to the general practitioner led family physician model and let disease management be implemented.