北仑区县域医共体推进医防融合的实践与成效

Practice and effect of promoting the integration of chronic disease prevention and treatment by county medical community in Beilun District,Ningbo City

慢性非传染性疾病是影响人类健康生活的主要疾病,对家庭和社会造成沉重负担,加强慢病管理至关重要。文章介绍了在县域医共体框架下北仑区人民医院医疗健康服务集团慢性病“六师共管”的工作模式、智慧化服务和医管科研融合等特色做法,从而有效提升两慢病的规范管理率和控制率,促进家庭医生签约服务、双向转诊、远程医疗,实现“六师共管”成效,为推进县域医共体慢病医防融合提供了实践经验。

Chronic non-communicable diseases are the principal diseases that affect human health and cause heavy burdens on households and society,so it is crucial to strengthen chronic disease management.In this paper,we elaborated the specific measures for managing chronic diseases in Medical and Health Service Group of People's Hospital(Beilun Branch)under the framework of county medical community,including the working mode of“co-management by six types of healthcare professionals(clinicians,nurses,pharmacists,dieticians,psychological consultants and health managers)”,innovative health services and integration of medical services,management and scientific researches,thus improving the standardized management and control rates of chronic diseases,promoting contracted family doctor services,two-way referral,and telemedicine,achieving results in the“co-management by six types of healthcare professionals”,and providing valuable practical experience in promoting integration of chronic disease treatment and prevention nationwide.