基于医护组合团队模式下的社区慢性病管理

Chronic disease management in community based on the model of team of doctors and nurses

目的:分析医护组合团队对社区慢性病的管理效果。方法:组建、推行医护组合团队及模式,强调全科医生与社区护士固定组合,明确全科医生与社区护士职责,并完善协调机制,全权负责辖区慢性病患者的全方位管理。结果:管理1年后,辖区慢性病患者对健康生活方式的接受度更高,血压控制达标率提升8.90%、血糖控制达标率提升9.35%,慢性病得到有效控制;全科门诊首诊就诊率增长12.92%,患者满意率也提高3.33%。结论:医护组合团队模式是一种有效的社区慢性病管理模式,能更加合理地配置现有医疗资源,全方位管理慢性病患者,有效促进居民健康。

Objective:To analyze the effect of team of doctors and nurses on community chronic disease management.Methods:Set up and implement the combination team and mode of doctors and nurses,emphasize the fixed combination of general practitioners and community nurses,clarify the responsibilities of general practitioners and community nurses,and improve the coordination mechanism,be fully responsible for the comprehensive management of chronic disease patients in the jurisdiction.Results:After one year of management,patients with chronic diseases in the jurisdiction had higher acceptance of healthy lifestyle,the compliance rate of blood pressure control increased by 8.90%,the compliance rate of blood glucose control increased by 9.35%,chronic diseases were effectively controlled.The first visit rate of general outpatient service increased by 12.92%,the satisfaction rate of patients was also increased by 3.33%.Conclusion:The model of team of doctors and nurses is an effective community chronic disease management model,it can allocate the existing medical resources more reasonably,manage the patients with chronic diseases in an all-round way,and effectively promote the health of residents.