分级诊疗背景下构建“心脏康复在社区”全科诊疗路径的实施对策

Implementation strategies for constructing a clinical path of’cardiac rehabilitation in the community’for community general practice care under hierarchical medical system

目的我国社区卫生服务已进入学科内涵建设期,社区卫生机构开展特色专科建设是当前提升基层服务内涵、留存基层健康需求的针对性策略。而特色专科依赖于特色专病的解决方案建设,本研究拟对龙华社区"心脏康复在社区"项目2年实践进行复盘。在抓住成功构建重点专病社区全科诊疗路径应把握的核心要素与基本原则基础上,进一步探讨如何在学科建设的高度上,系统化、结构化地梳理出"构建重点专病社区全科诊疗路径的实施对策"。方法围绕实施对策的"服务内涵与组织架构及科室设置;人员准入及培养策略;技术供应方筛选及合作机制建立;服务流程开发与配套设施配备;落地实施方案建立与质控及评价体系建立结合具体实践"等5个方面,介绍龙华社区的具体实践和经验启示。结果通过5个方面的回顾和梳理,充分挖掘和呈现了龙华社区的具体实践,5个方面的框架可用于未来对学科建设程度进行盘点的工具;整理出了龙华社区在实践过程中所用到的2张清单、3件工具和1套流程,是社区今后进行技术开发时可供参考的工具包。结论以上5个维度的充分准备和落实,是"心脏康复在社区"类具有社区和全科特征项目平稳和扎实落地的保障。龙华社区建设过程中所开发和使用的2张清单、3件工具和1套流程,可帮助同行把握细节、指导落地。

Objective China’s community health service has entered the period of disciplinary connotation construction.The construction of specialised community health institutions is the current targeted strategy to improve grassroots services and retain the needs of grassroots health.The specialty disciplinary depends on the solution construction of the specialty critical illness.This study aims to review the two-year practice of’cardiac rehabilitation in the community’in Longhua community by understanding the core elements and basic principles in the successful construction of community general practice care on critical illness.This study discusses how to systematise and structurally comb out the’implementation countermeasures to construct the clinical path of community general practice care on critical illness’in the height of discipline construction.Methods Centre on the five aspects of’service connotation and organisational structure and department setting around implementation countermeasures;personnel access and training strategies;technology supplier selection and cooperation mechanism establishment;service process development and supporting facility deployment;ground implementation plan establishment and quality control and evaluation system Establishing a combination of specific practices’,introduced Longhua’s specific practices and experience.Results Through the review and carding of the five aspects,the concrete practice of Longhua community was fully explored and presented.It has sorted out two lists,three tools and a set of process used by Longhua community in the practice process,which is a reference kit for future technology development of the community.Conclusion The full preparation and implementation of the above five dimensions is the guarantee for the smooth and solid implementation of the’cardiac rehabilitation in the community’project with the characteristics of community and general practice.The two lists,three tools and a set of process developed and used in the construction of Longhua community can help peers grasp the details and guide the implementation.