三甲医院全程健康管理模式下的家庭医生签约服务实践

Practice of family physician contracted service under the whole process health management model in tertiary a-level hospital

目的家庭医生签约服务已在我国各区域社区卫生服务中心进行了有益有效的实践,三甲医院的家庭医生签约服务实践形式多以社区卫生服务中心为主体,与社区单位进行联合,向基层医务人员提供技术指导和知识培训,并为双向转诊提供支撑。三甲医院独立进行健康管理的家庭医生签约服务模式尚有待探索。方法分析四川大学华西医院全科医学科近3年来开展的基于全程全周期健康管理的家庭医生签约服务模式实践,总结其运营机制,勾勒三甲医院家庭医生签约的服务模式,并分析三甲医院推行家庭医生签约服务可能存在的问题。结果四川大学华西医院全科医学科在家庭医生签约服务的过程中制定了签约医疗组管理制度和各岗位工作流程,完善签约人群的健康管理流程。全科医生团队通过在不同时间节点的介入,对家庭签约人群提供力所能及的、全方位的医疗照护及全程的健康管理,并与社区卫生服务中心组成上下联动机制,借此推动分级诊疗的落实。以全科医生团队为纽带,建立了三甲医院全程健康管理的家庭医生签约服务模式,形成全程健康管理服务平台。但如何向签约个体更好地提供三甲医院的优质诊疗技术、实行与社区的联动,以及对接“健康中国2030”尚需要进一步思索。结论三甲医院也可开展基于全程健康管理的家庭医生签约服务模式,为医疗资源的合理优化利用、分级诊疗的推进、医疗服务质量的提高提供有益的探索。

Objective The family physician contracted service has carried out beneficial practices in China's community health service centers.Most of the tertiary A-level hospitals take community health service centers as the main body,and cooperate with community units to provide technical guidance and knowledge training for medical staff,and provide support for two-way referrals.The family physician contracted service model independently carried out in tertiary A-level hospitals needs to be explored.Methods We analyzed the family physician contract service based on the whole process health management conducted by the General Medicine Department of West China Hospital of Sichuan University in the past three years,summarized its operation mechanism,outlined the service model,and analyzed the possible problems in the implementation in the tertiary A-level hospitals.Results We have established the management organization structure,the management system of the contracted medical team,formulated the work process of each job posting,and improved the health management process of the contracted personnel.The family doctor team provides all-round medical care and whole process health management for family contract patients at different time nodes,and forms an up-down linkage mechanism with the community center to promote hierarchical diagnosis and treatment.With the family doctor team as the link,the family doctor contract service mode of whole process health management in tertiary A-level hospital has been established,forming a whole process health management service platform.How to better provide the contracted individuals with high-quality diagnosis and treatment technology of tertiary A-level hospitals,and how to implement the community link and connect with Healthy China 2030 needs further consideration.Conclusion The tertiary A-level hospital can also carry out the contracted service mode of family doctor based on the whole process health management,so as to provide beneficial exploration for the rational and optimal utilization of medical resources,promote hierarchical diagnosis and treatment,and improve the quality of medical service.