大型综合医院与社区卫生服务中心联合开展慢性肝病综合管理的探索

Collaboration between tertiary hospital and community health service center in comprehensive management of chronic liver diseases in the community

慢性肝病是常见病、多发病。为使慢性肝病患者得到有效诊疗与管理,四川省人民医院联合成都市双水碾社区卫生服务中心,探索建立以大型综合医院技术为依托,社区卫生服务中心为场所,在专家指导下,以社区全科医生为骨干,患者及患者家属参与的"医院-社区-患者-家庭"四位一体分层递进的慢性肝病管理模式。通过阐述团队内大型综合医院专科医师、社区全科医生联合开展特色慢性肝病综合管理的措施及初步实施效果,以期为其他地区开展慢性肝病诊疗与管理提供参考。

Chronic liver diseases,including chronic hepatitis,autoimmune liver disease,alcoholic liver disease,cirrhosis,fatty liver disease,drug-induced liver injury and so on,are common and important disorders in China.A hospital-community-patient-family integration management model for chronic liver diseases has been implemented since 2018 in Shuangshuinian Community Health Service Center collaborated with Sichuan Provincial People′s Hospital.Patients were taken care by general practitioners in the community health center under the guidance of hospital specialists,and with the active participation of patients and their family.This article introduces this integrated management model and the preliminary accomplishment to provide a reference for the management of patients with chronic liver diseases in the community.