紧密型县域医共体医防融合促进慢病管理研究——以福建省三明市为例

Study on Promoting Chronic Disease Management by the Integration of Medical Care and Prevention in Compact County-level Medical Community——Taking Sanming City of Fujian Province as an Example

目的:分析福建省三明市12家紧密型县域医共体在医防融合政策下开展慢病管理的成效,提出优化建议。方法:采用PEST分析法,从体制/政策、经济/财务、社会/人员、技术/管理四个方面分析医共体医防融合的宏观环境,归纳慢病管理的影响因素。结果:三明市医共体医防融合政策以家庭医生团队、疾病管理队伍为突破口,采用“四早”“四分”“积分制”“MDT”慢病管理模式,依托慢病一体化管理信息系统持续推进,成效初显,比如高血压、糖尿病的管理率、控制率逐年提高,并发症得到控制。结论:医共体医防融合政策对慢病管理具有积极作用,但也存在一些问题,需要健全体制机制,强化基层服务能力,同时需要政府因地制宜地调整宏观政策,从而实现可持续发展。

Objective To analyze the effectiveness of chronic disease management in 12 compact county-level medical communities in Sanming City of Fujian Province under the policy of the integration of medical care and prevention,and to put forward optimization suggestions.Methods Using the PEST analysis method,the macro-environment of the integration of medical care and prevention in compact county-level medical communities was analyzed from four aspects:system/policy,economy/finance,society/personnel and technology/management,and the influencing factors of chronic disease management were summarized.Results The policy of integration of medical care and prevention in Sanming City took the team of family doctors and disease management team as the breakthrough point,adopted chronic disease management model of"four early","four aspects","integral system"and"MDT",and relied on the integrated management information system for chronic diseases to continue to advance,with initial results.The management rate and control rate of hypertension and diabetes increased year by year,and the complications were suppressed.Conclusion The policy of integration of medical care and prevention in compact county-level medical communities has a positive effect on the management of chronic diseases,but there are also some problems.It is necessary to improve the mechanism and system,strengthen the service capacity at primary level,and adjust the macro-policy according to local conditions,so as to achieve sustainable development.