分级诊疗背景下三级医院与社区协作慢病管理分析

Analysis of Chronic Disease Management of Tertiary Hospital-Community Collaboration under Background of Hierarchic Diagnosis and Treatment

目的在构建“复兴月坛”紧密型医联体的实践中,通过政策引导和制度落实,有效缓解看病贵、看病难问题,缓解医患关系紧张的局面,提高基层医疗机构的卫生服务能力,最终实现患者、三级医院和社区卫生服务中心多赢的局面。方法以复兴医院为依托,以月坛社区卫生服务中心作为主体,以下属的10个社区卫生服务站为基础,构建“复兴月坛”紧密型医联体,复兴医院对月坛社区卫生服务中心进行行政管理和日常业务指导,各个社区卫生服务站承担社区内的基本医疗卫生服务和预防保健工作。结果通过在医院与月坛社区卫生服务中心、各社区卫生服务站建立双向转诊通道,逐步改变慢病患者的首诊选择,降低慢病患者的疾病负担,同时慢病管理取得明显的成效,实现管理一体化、基本医疗一体化。结论建立基层首诊、双向转诊、急慢分治、上下联动的分级诊疗制度,是我国医药卫生体制改革的重点工作之一,有效的分级诊疗制度,通过医院与基层医疗卫生机构之间的分工协作机制,可以实现合理配置医疗资源,对于形成“小病在社区、大病进医院、康复回社区”的有序就医格局,具有重要意义[1]。

Objective In the practice of constructing close-knit medical association of“Fuxing-Yuetan”,by policy guiding and institution implementing,we effectively relieved the problem of difficult and expensive medi-cal treatment,and improved the medical service ability of primary medical institution.Finally,we made an all-win situation among patients,tertiary hospitals and community health service centers.Methods Relying on Fuxing Hospital and taking Yuetan Community Health Service Center as the main body,and based on 10 subordinate com-munity health service stations,we constructed the close-knit medical association of“Fuxing-Yuetan”.Fuxing Hospital provided administration and operational guidance to Yuetan Community Health Service Centers,and com-munity health service stations took the responsibility of basic medical service and primary prevention and health-care.Results The dual referral system between Fuxing Hospital and Yuetan Community Health Service Center,gradually changed the first visit choices of chronic patients,and reduced their burden of disease.Effect of chronic disease management in this region improved obviously.Conclusion The institution of hierarchic diagnosis and treatment,which including first visit in community,dual referral,distinguishing the acute and chronic diseases,making joint efforts,takes an importance place in Chinese medical and health system reform.Effective hierarchic diagnosis and treatment could make reasonable medical resources allocation,through the collaboration between ter-tiary hospitals and primary medical service institutions,and make great sense to a well-organized medical service pattern.