慢性非传染性疾病社区健康管理模式的内涵及对我国的启示

Connotation of the community health management models of chronic non-communicable diseases and its revelations to our country

随着我国人口老龄化进程的加快以及慢性非传染性疾病患病率的不断上升,如何在社区对慢性非传染性疾病展开更精准有效的管理关乎我国人口健康和社会发展。本研究就慢性非传染性疾病社区健康管理的背景与发展,系统阐述其内涵、原则及方法,总结国内外慢性非传染性疾病社区健康管理模式,并分析我国存在的不足和相关改进措施,探究我国慢性非传染性疾病社区健康管理的未来发展方向。目前我国慢性非传染性疾病社区健康管理仍处于初期探索阶段,主要模式包括家庭医生签约服务模式、医院-社区-家庭联动模式与医养结合模式。相比之下,国外慢性非传染性疾病社区健康管理理念起步更早,创立了诸如美国糖尿病预防计划、澳大利亚新南威尔士州慢性病预防管理模式、创新型慢性病照护框架等一系列各具特色、行之有效的社区慢性病管理模式。上述管理模式对我国有一定的借鉴意义,包括:系统高效地整合资源;根据社区人群的特点制定慢性病管理计划;注重居民的自我健康管理意识。目前,我国慢性非传染性疾病控制体系已取得明显进步,但依然存在着医疗资源配置结构性失衡和低效率、分级诊疗制度尚未完善、人群自我健康管理意识和能力欠缺等问题。未来仍需深入开展针对性的慢性病健康教育,建立人才培养长效沟通机制,完善以家庭为单位的分级诊疗制度。

With the acceleration of the aging process of the Chinese population and the rising prevalence of chronic non-communicable diseases,a strategy for the accurate and effective management of chronic non-communicable diseases in community health service centres is crucial for health and social development of the Chinese population.Based on the background and development of community health management of chronic non-communicable diseases,this study systematically discusses the connotation,principles and methods of community health management of chronic non-communicable diseases,summarises foreign and domestic community health management models for chronic non-communicable diseases,analyses the shortcomings and relevant improvement measures in China,and explores the future development direction of community health management of chronic non-communicable diseases in China.Nowadays,community health management of chronic non-communicable diseases in China still lacks progress.Domestic management models include the family-doctor contract service model,hospital-community-family linkage model and medical-care combination model.By contrast,the concept of community health management of chronic non-communicable diseases in foreign countries is proposed earlier,and a series of distinctive and practical models,such as the National Diabetes Prevention Program,New South Wales Chronic Disease Prevention and Management Model in Australia and Innovative Care for Chronic Conditions Framework,has been developed.The above management model has certain reference significance for our country,including the systematic and efficient integration of resources,formulation of chronic disease management plans based on the characteristics of specific communities and a focus on residents’awareness of self-health management.At present,China’s chronic non-communicable disease control system has made significant progress,but there are still problems such as structural imbalance and low efficiency of medical resource allocation,imperfect hierarchical diagnosis and treatment system,and lack of awareness and ability of self-health management of the population.In the future,it is still necessary to carry out targeted health education on chronic diseases,establish a long-term communication mechanism for talent training,and improve the hierarchical diagnosis and treatment system based on families.