宁夏基层实施慢性病闭环管理探讨

Discussion on primary closed-loop management mode of chronic diseases in Ningxia

实施"院前-院中-院后"慢性病闭环管理,是提升当前慢性病管理效能的有效方法。作者简述了宁夏地区基层实施慢性病闭环管理的可行性、建设内容和亟待解决的问题,重点阐述了构建面向多病种的慢性病管理路径、实施基于"三师共管"的慢性病闭环管理、推进基层医师的培养和提升规范化管理水平、建立以社区为中心的慢性病三级防治体系、推广慢性病管理与干预信息支撑平台等内容,以提高基层慢性病管理实施效果,提升患者健康水平和生存质量,降低人民群众的经济负担。

The pre-during-post hospital closed-loop management of chronic diseases is an efficient way to upgrade the current chronic disease management level.The authors described the feasibility,what to build and imperative problems in implementing such a closed-loop management in primary level in Ningxia.The introduction focused on the construction of a chronic disease management path for multiple diseases,the implementation of a closed-loop management model for chronic diseases based on the"three in one model(specialist-family physician-health manager)",the promotion of primary physician training and standardization management level,as well as the establishment of a community-centered three-level prevention and treatment system for chronic diseases.These efforts aim at promotion of chronic disease management outcomes,elevation of patients′health and quality of life,and minimization of people′s economic burden.