家庭医生团队“三师共管”社区老年慢性病健康管理模式构建与效果评价

Construction and Effect Evaluation of Health Management Model of Elderly Chronic Diseases in Community Under the"Three Divisions Co Management"of Family Doctor Team

目的:构建应用智能化平台的家庭医生团队"三师共管"慢性病管理模式,并评价其在社区老年慢性病患者中的应用效果。方法:搭建智能化健康管理平台,并于2018年6月起,选取深圳市福田区益田社区健康服务中心65岁以上的高血压患者和糖尿病老年患者各500例,采用以家庭医生团队为基础的"三师共管"管理模式对其进行为期1年的健康管理,比较患者干预前后的血压、血糖、BMI、生活方式等情况,分析其管理效果。结果:共482名高血压患者和479名糖尿病患者完成了1年的随访干预。干预后,高血压患者收缩压、舒张压、空腹血糖和BMI均显著低于干预前,差异均有统计学意义(P<0.05)。干预后,糖尿病患者的空腹血糖和BMI均显著低于干预前(P<0.05)。干预后,高血压和糖尿病患者吸烟和饮酒的比例均低于干预前,差异均有统计学意义(P<0.05);干预后,高血压和糖尿病患者运动30 min以上的频率均显著多于干预前,差异均有统计学意义(P<0.05)。结论:基于家庭医生团队的"三师共管"慢性病管理模式对社区老年慢性病患者的健康管理效果满意,值得在社区中推广。

Objective:To construct the chronic disease management mode of"three divisions co management"of the family doctor team based on the intelligent platform,and to evaluate its application effect in the elderly chronic disease patients in the community.Method:Build an intelligent health management platform,and since June 2018,select 500 hypertension patients and 500 diabetes elderly patients over 65 years old in Yitian community health service center of Futian District,Shenzhen City,and used the"three division co management"management mode based on the family doctor team to carry out a one-year health management,the blood pressure,blood sugar,BMI and lifestyle of the patients before and after intervention were compared,and the management effect was analyzed.Result:A total of 482 hypertensive and 479 diabetic patients completed a 1-year follow-up intervention.After intervention,systolic blood pressure,diastolic blood pressure,fasting blood glucose and BMI in hypertensive patients were significantly lower than those of before intervention,with statistically significant differences(P<0.05).After intervention,fasting blood glucose and BMI were significantly lower in patients with diabetes than those of before intervention(P<0.05).After intervention,the proportion of smoking and drinking in patients with hypertension and diabetes were lower than those of before intervention,and the differences were statistically significant(P<0.05).After intervention,the frequency of exercise for more than 30 min in patients with hypertension and diabetes were significantly higher than those of before intervention,and the differences were statistically significant(P<0.05).Conclusion:Based on the family doctor team,"three division co management"chronic disease management model is satisfied with the health management effect of elderly chronic disease patients in the community,which is worth promoting in the community.