深圳市某街道区域社区健康服务中心开展家庭医生网格化管理模式探讨

Study on the Mode of Family Doctor Grid Management at a Regional Community Health Service Center of Shenzhen

目的建立网格化家庭医生服务团队,探讨网格化社区卫生服务模式,旨在建立社区卫生服务机构家庭医生网格化管理模式。方法在深圳市某街道区域建立由全科医生、护士、公卫医师、健康促进员、社区网格员构成的家庭医生团队,每个团队负责若干个网格片区,追踪网格内重点人群,并统计2019-2020年重点人群健康管理情况。结果区域内共组建62个家庭医生团队,2020年共追踪65岁及以上老年人6352人,高血压患者9142人,2型糖尿病患者3452人;相对于2019年、2020年居民健康档案378508份,增加了139.91%;高血压患者健康管理人数8042人,增加了62.60%;2型糖尿病患者健康管理人数2914人,增加了71.31%;65岁及以上老年人健康管理人数2314人,增加了58.82%。结论家庭医生网格化管理模式充分发挥了社区资源的优势,提高了社区卫生服务的针对性和覆盖面,下一步应进一步完善网格化家庭医生团队,拓宽网格化管理内容,提升网格化管理内涵。

Objective To establish the grid family doctor service mode at community health service center.Methods A family doctor team composed of general practitioners,nurses,public health doctors,health promoters and community grid members was established.Each team was responsible for several grid areas,tracking the key population in the grid,and making statistics on the health management of key population in 2019 and 2020.Results The street had set up 62 family doctor teams,tracking 6352 elderly people over 65 years old,9142 patients with hypertension and 3452 type 2 diabetes patients in 2020.The number of resident health records was 378508 in 2020,which increased by 139.91%.The number of hypertension patients was 8042,which increased by 62.60%.The number of type 2 diabetes patients was 2914,which increased by 71.31%.The number of elderly people over 65 years old was 2314,which increased by 58.82%.Conclusion The grid management mode of family doctors gives full play to the advantages of community resources,and improves the pertinence and coverage of community health services.The next step is to further improve the grid family doctor team,broaden the scope of grid management,and enhance the connotation of grid management.