分级诊疗背景下构建“心脏康复在社区”全科诊疗路径的核心要素分析

Analysis of the core elements of the successful construction of"cardiac rehabilitation in the community"clinical path of community general practice care under hierarchical medical system

目的明确分级诊疗背景下,以专科先进适宜技术社区落地为技术来源,以技术引进再创新为承接吸收原则,成功构建重点专病的社区全科诊疗路径将要面对的挑战和重难点以及应对策略的核心要素和基本原则。方法于2020年3月,以龙华社区"心脏康复在社区"项目为依托,通过关键知情人回顾总结、科室历史资料查阅整理等方法,梳理该项目在2年建设周期中的预初决策、建设过程和建设成果,同时纳入文献检索和专家判断,对其中的实践经验进行总结凝练。结果得出4个核心要素:做好基础保障,让机构成员认识到发展业务引进技术的重要性和必然性;慎重选择技术,确保技术能够切实助力社区和全科的发展;重视技术接口,将专科优势做好翻译和转换融入全科范畴和社区环境中;做透技术渗入,让技术不只是解决心血管疾病问题而是解决所有同类慢病的管理问题。结论 "心脏康复在社区"这类符合全科特征的项目,完成从专科引进落实到社区是一个十分复杂而综合的特大工程,面对涉及角色多、所用技术复杂、社区资源配置不足的现状,唯有在识别所有需要及可用资源,通过科学、专业、周密的合作整合和协调获得这些资源,再有机整合后和盘向社区居民输出的基础上,重视内部动员、外部协调、过程管理、技术上举一反三等要素,才有落地可能。

Objective Under the background of hierarchical diagnosis and treatment,with the application of advanced and appropriate technologies in specialized specialty communities as the source of technology,and the principle of technology introduction and re-innovation as the principle of acceptance and absorption,successfully constructing a community general medical diagnosis and treatment path for key specialized diseases,this study intends to clarify the challenges and major difficulties,and the core elements and basic principles of the countermeasures.Methods In March 2020,the Longhua"cardiac rehabilitation in the community"project was used as the research object.The preliminary decisionmaking,construction process and construction results of the project in the two-year construction period were sorted out by key insiders reviewing and historical data of the department sorting,and then summarized and condensed the practical experience by literature search and expert judgment.Results Four core elements were drawn;do a good job in basic guarantees,make the members of the organization realize the importance and inevitability of introducing technology for business development;choose technology carefully to ensure that technology can actually help the development of the community and the whole department;value technology interface,and integrate the advantages of specialization into translation and conversion into the general practice and community environment;through technology penetration,let technology not only solve the problem of cardiovascular disease but also the management of all chronic diseases of the same kind.Conclusion The"cardiac rehabilitation in the community"is a very complex and comprehensive project,which meets the characteristics of general practice.It faces the current situation of multiple roles,complex technology,and insufficient community resource allocation.Only by identifying all needs and available resources,and obtaining these resources through scientific,professional,and careful cooperation,integration and coordination,and then organic integration and export to community residents,attach importance to internal mobilization,external coordination,process management.It is technically inferior to other factors to make it possible to work.