高年资护士六元联动城市医联体工作模式实践研究

A study on urban medical consortium work pattern of the six-party linkage involving senior nurses

目的:通过下沉三甲医院的高年资护士到社区,围绕老年人、孕产妇、婴幼儿以及慢病,开创城市医联体工作模式。方法:高年资护士六元联动社区居民、社区护理、家庭医生、医院医疗专家、医院护理专家、院级医联体部门,开展社区居民健康管理工作。结果:2017年9月-12月,某医院4位高年资护士驻点在庐阳区3家社区中心,健康教育普及率100%,血压控制率达72%,血糖有效控制率达65%;上转患者比2016年同期增幅132.75%,下转患者比2016年同期增幅210%;社区居民满意度平均上浮7.4%。结论:高年资护士介入的六元联动城市医联体工作模式,创新了社区"三人四病"服务模式,提高了社区居民满意度及社区团队的服务能力。

Objective:Through the sinking of the three-grade class-A hospital nurses to the community health management is carried out around the elderly, pregnant women and infants, as well as chronic diseases to open up the innovative urban medical association work pattern. Methods: Senior nurses carry out health management of community residents through linking community residents, community care, family doctors, hospital medical experts, hospital nursing experts, hospital medical association. Results: From September 2017 to December 2017, four senior nurses from the hospital were located at 3 community centers in Luyang district to carry out special outpatient service. The penetration rate of healthy education was 100%, the blood pressure control rate was 72%, and the effective control rate of blood glucose was 65%.The total number of upturned patients, an increase of 132.75% and the patients with a lower transfer rate, a 210% increase over the same period in 2016.The satisfaction of community residents was 7.4% on average. Conclusion: The six-part linkage urban medical service with the involvement of senior nurses has innovated the community "three people four disease" service model, improving community satisfaction and community service capacity.