家庭医生团队服务对社区高血压患者的管理方式分析

Analysis on the Management Mode of Community Hypertension Patients Under Family Doctor Team’s Service

目的探讨优化家庭医生团队式服务对高血压管理方式的差异性改变,为社区高血压患者管理模式提供理论依据。方法通过随机对照研究的方法,比较干预组和对照组接受优化家庭医生团队式服务1年后两组人群在高血压专科复诊情况、自我管理和参加社区随诊等健康管理方式的差异。结果服务后,患者的健康素养明显提升,采取定期高血压专科随访人数和定期到社区医院随访的患者增加,差异有统计学意义(P<0.05),两组患者在健康小组参与情况,用其他方式管理和不采取任何管理方式的人数改变无统计学差异(P>0.05)。结论通过本次优化配置家庭医生团队进行团队式管理,社区高血压患者的健康管理方式有所促进,提升了患者专科复诊和社区随诊的依从性。

OBJECTIVE To explore the difference changes of family doctor team service in hypertension management mode and to provide theoretical basis for community hypertension patients management mode. METHODS A randomized controlled study was conducted to compare the differences of health management modes in hypertension specialty,self-management,community follow-up and so on between intervention group and control group one year after receiving optimized family doctor team service. RESULTS After the service,the health literacy of patients was significantly improved,and the number of patients who took regular follow-up visits to hypertension specialty and community hospitals increased,with statistical significance(P<0.05). There was no significant difference in the number of patients who participated in the health group,managed by other methods and did not adopt any management methods between these two groups(P>0.05). CONCLUSION By optimizing the allocation of family doctor team for team management,the health management mode of hypertension patients in the community had been promoted,and the compliance of patients with specialist reexamination and community follow-up had been improved.