社区慢性病管理骨干对老年慢性病管理体验的质性研究

A Qualitative Study on the Experience of Community Chronic Disease Management Backbones on Elderly Chronic Disease Management

目的了解社区慢性病管理骨干对老年慢性病的管理体验,为提高我国慢性病管理水平提供参考依据。方法采用目的抽样法选取12名社区管理骨干进行半结构式深入访谈,应用MAXQDA软件、框架分析法进行资料分析及主题提炼。结果提炼出3个主题:主题1为社区老年慢性病管理工作模式较为成熟:政府给予政策指导,责任制管理团队分工明确,质量控制制度较为完善;主题2为老年慢性病管理工作仍面临诸多挑战:财政支持不足,信息管理系统不统一,工作人员留任和离职状况不容乐观;主题3为老年慢性病管理需要进一步完善:提高老年人群认可度与参与度,完善双向转诊,推行家庭医生签约模式。结论社区老年慢性病管理工作模式较为成熟,今后应加大对老年慢性病管理的财政支持,提高老年人群的认可度和参与度,完善并统一信息管理系统,加强社区与上级医院的上下联动,拓宽家庭医生签约模式的覆盖面,探索提高留任与减少离职的对策。

Objective To understand the management experience of the backbone of community chronic disease management in elderly chronic diseases,and to provide reference for improving the management of chronic diseases in my country.Methods Used the method of objective sampling,12 key community management personnel were selected for semi-structured in-depth interviews.Used MAXQDA software and frame analysis method for data analysis and theme extraction.Results Three themes were extracted:Theme 1 was that the management of elderly chronic diseases in the community was relatively mature:the government provides policy guidance,the responsibility system management team had a clear division of labor,and the quality control system was relatively complete.Theme 2 was that the management of chronic diseases in the elderly still faces many challenges:insufficient financial support,inconsistent information management systems,and the situation of staff retention and departure was not optimistic.Theme 3 was that the management of chronic diseases in the elderly needs to be further improved:improve the recognition and participation of the elderly,improve two-way referral,and implement the family doctor contract model.Conclusion The community management of chronic diseases in the elderly is relatively mature.In the future,we should increase financial support for the management of chronic diseases in the elderly,improve the recognition and participation of the elderly,and improve and unify the information management system,strengthen the linkage between the community and higher-level hospitals,expand the coverage of the family doctor contract model,and explore countermeasures to improve retention and reduce turnover.