慢性病延续性照护模式与政策引导双轨融合的研究

Dual track integration of continuous care model and policy guidance for chronic diseases

目的:构建并推广慢性病三元联动延续性照护模式,为慢性病防控相关政策的制定提供依据。方法:参照WHO慢性病创新照护模式,以“医院、社区、家庭”为三界面,以“信息、管理、关系”为核心关系,构建慢性病“医院-社区-家庭”三元联动延续性照护模式;通过优质护理资源向基层辐射、个案管理、“互联网+护理服务”、慢性病健康科普等促进机制破除模式运行壁垒;以慢性病单病种为例,基于“结构-过程-结局”构建脑卒中患者延续性护理质量评价指标体系,为规范慢性病延续性护理的有效落实提供评价工具。结果:通过模式的运行,引导了优质护理资源下沉、护士多点执业、社区护理中心建设、科普工作纳入职称考评等政策的制定;优化了医疗资源配置,提升了社区护理服务能力;改善了慢性病患者健康结局,提高了其自我管理能力。结论:慢性病“医院-社区-家庭”三元联动延续性照护模式的构建和运行在引导慢性病政策制定、优化医疗资源分配、提高社区护理能力和改善患者健康结局等方面发挥着重要作用,政府、医院、社区、家庭及患者须协同发力,真正实现慢性病患者出院后连续化、全程化的照护。

Objective:To construct and promote the three-way linkage and continuous care model for chronic diseases,and to provide a basis for the formulation of relevant policies for chronic disease prevention and control.Methods:Based on WHO's innovative nursing model for chronic diseases,a three-way linkage and continuous nursing model of"hospital,community and family"was constructed with"hospital,community and family"as the three interfaces and"information,management and relationship"as the core elements.Innovative promotion mechanisms such as"high-quality nursing resources radiating to the grassroots,case management,Internet+nursing services,and chronic health science popularization"have been put forward to break the operation barriers of the model.Based on"structure-process-outcome",an evaluation index system for the quality of continuous care for stroke patients was established to provide an evaluation tool for the effective implementation of standardized continuous care for chronic diseases.Results:Through the operation of the model,it guided the formulation of policies such as the sinking of high quality nursing resources,multi-point practice of nurses,construction of community nursing centers and popularization of science into the evaluation of professional titles,optimized the allocation of medical resources and enhanced the ability of community nursing service.It also improved the health outcome and self-management ability of chronic disease patients.Conclusion:The construction and operation of the"hospital-community-family"three-way linkage and continuous care model for chronic diseases plays an important role in guiding the formulation of chronic disease policies,optimizing the allocation of medical resources,improving community nursing capacity and improving the health outcomes of patients,etc.The government,hospitals,communities,families and patients need to work together to truly achieve continuous and whole-process care for patients after discharge.