社区居民非药物低成本全周期精准健康管理模式在慢性病防控领域的应用

The application of non drug,low-cost and full cycle accurate health management model in the field of chronic disease prevention and control for community residents

本项目基于“健康社区”建设在推进“健康中国”进程中的战略地位及重要作用,立足于探索一种新形势下社区居民健康管理服务的“新模式”。借鉴佰善健康15年工作实践,经过对4个社区2万多名居民的调查研究,确立了以健康大数据中心为依托的线上服务,结合以非药物康复技术为核心的线下服务,形成《10 min社区精准健康管理服务圈》的服务模式,并应用于社区居民健康管理和慢病防控,效果显著。填补了基层医疗卫生中心在该服务方面的空白,实现“院前院后”居家慢病防控与康复,降低个人及国家医疗开支,提升居民健康素养。本文主要从社区居民未被满足的健康需求以及国家对慢病管控的需求出发,重点阐述该模式的构成要素、创新点及其应用于慢性病管控的可行性。

The project is based on the strategic position and important role of"healthy community"construction in promoting“healthy China”,and is based on exploring a"new mode"of community residents'health management service under the new situation.Based on the work practice of Baishan health for 15 years and the investigation of more than 20000 residents in four communities,we have established online services based on health big data center,the service mode of"10 minutes community precise health management service circle"is formed by combining offline service with non drug rehabilitation technology as the core,and it is applied to community residents'health management and chronic disease prevention and control,the effect is significant.It fills in the gap of the basic medical and health center in the service,realizes the prevention,control and rehabilitation of home-based chronic diseases"before and after the hospital",reduces personal and national medical expenses,and improves the health literacy of residents.Based on the unsatisfied health needs of community residents and the needs of the state for chronic disease control,this paper focuses on the elements of the model,innovation points and the feasibility of its application in chronic disease control.