上海市社区卫生服务中心慢病管理实施情况分析

Analysis of chronic disease management implementation in community health service center in Shanghai

目的对上海市社区卫生服务中心(以下简称“社卫”)慢性非传染性疾病(以下简称“慢病”)管理整体实施情况展开调研,评估和改进上海市社区卫生服务中心的慢病管理现况。方法于2022年7月整群选取上海市247家社区卫生服务中心为研究对象,对上海市全科医学临床质控中心的社区医疗机构质控数据中有关慢病管理部分的数据(包括客观质控资料与主观问卷调研情况)进行描述性分析。结果共有238家社区卫生服务中心参与调研,其中96.2%(229家)的社卫设有明确的慢病管理考核标准,考核指标主要覆盖了患者就医满意度、健康素养问卷完成率及患者回访率等;共234家社卫设有慢病管理系统,其中有98.3%的社卫建立健康管理平台,但仅67.2%的社卫定期更新数据,且有29.8%的社卫存在信息记录不全的问题。以高血压管理为例,90.7%的社卫为患者建立了规范的健康档案,且所有社卫都进行了随访。目前社区卫生服务中心在实施慢病管理方面的需求主要包括个体化管理经验、移动管理工具、风险评估方法、转诊平台等;执行过程中遇到的主要困难包括信息处理繁杂、患者管理不一致、时间投入过长和考核标准复杂等。结论以社区为核心的慢病管理模式已初步形成,之后需聚焦现有问题与需求,通过优化慢病管理培训与评价体系、加速建设基层医疗信息标准化、强化社区慢病管理支持工具等多个维度进一步推进社区卫生服务中心慢病管理意识与能力的持续提升。

Objective To investigate the overall implementation of chronic disease management in community health centers in Shanghai,and to assess and improve the current status of chronic disease management in community health centers in Shanghai.Methods In July 2022,a total of 247 community health centers in Shanghai were selected for analysis.A descriptive analysis was conducted on data related to chronic disease management,including objective quality control data and subjective questionnaire surveys,sourced from the Shanghai Clinical Quality Control Center of Family Medicine.Results A total of 238 community health centers participated in the study,96.2%(229 centers)had established clear assessment criteria for chronic disease management,primarily focusing on patient satisfaction,health literacy questionnaire completion rates,and patient return visit rates.In the study,98.3%of the 234 social health centers had a chronic disease management system,but only 67.2%of them regularly update their data,and 29.8%of them had incomplete information records.Taking hypertension management as an example,90.7%of centers maintained standardized health records for patients,and follow-up visits were conducted in all communities.The current needs of social guards in implementing chronic disease management mainly include individualized management experiences,mobile management tools,risk assessment methods,and referral platforms.The main difficulties encountered in the implementation process included cumbersome information processing,inconsistent patient management,excessive time requirements,and complex assessment standards.Conclusion A community-centered chronic disease management model has been established,but attention is needed to address existing challenges.To enhance awareness and ability in chronic disease management,it is essential to optimize training and evaluation system of chronic disease management,accelerate the standardization of primary healthcare information,and strengthen supportive tools for chronic disease management within the community in multiple dimensions.