医联体平台下北京某三级医院慢性病管理方式探索

The chronic diseases management model of a tertiary hospital in Beijing： exploration and practice ona medical alliance platform

慢性病管理是分级诊疗制度建设的突破VI，是推进健康中国建设的重要任务。作者对北京朝阳医院医联体平台下慢性病管理模式探索进行经验总结，重点阐述建立慢性病管理团队、制定慢性病诊疗规范及管理流程、打造互联互通的信息化平台等措施，以及模式实施后在引导患者下沉基层、提高基层慢}生病管理能力等方面的实践效果。在此基础上，对慢胜病管理模式现存问题进行探讨。

Chronic disease management is seen as a breakthrough point for establishing the hierarchical medical system, also an important task in building a healthy China. We summarized the experiences of the chronic diseases management of Beijing Chao-Yang Hospital, focusing on the establishment of a chronic diseases management team, development of the diagnosis and treatment norms and management procedures, and the interoperable information platform. And we introduced the practical effects, such as guiding patients to primary medical institutions, reducing medical costs, and improving the primary capabilities to manage chronic diseases, and existing problems of the management model.