澳大利亚慢性病管理计划及其对中国的启示

慢性病已经成为最主要的疾病负担,也是全球初级卫生保健和预防工作的重点。慢性病管理在改善患者健康结局、提高患者生活质量上发挥重要作用。本文通过实地学习和文献研究,介绍澳大利亚两种全科医学慢性病管理计划,即全科医生为慢性病患者提供的综合服务计划（GPMP）和全科医生对慢性病管理服务进行团队式协调（TCAs）。并与我国慢性病管理情况进行比较,提出我国应该从建立优质的全科团队,因地制宜地选择慢性病管理模式,发展“互联网+”技术,为慢性病管理提供技术支持等方面改进,不断探索符合我国国情的慢性病管理模式。

Australian Chronic Disease Management Plan and Its Enlightenment to China

Chronic disease has become the foremost cause of disease burden,and is also a priority for global primary and preventive health care.Chronic disease management plays an important role in improving the outcome,and quality of life in such patients.On the basis of studying chronic disease management in general practice and documentary research,this paper introduces two kinds of general practice chronic disease management plans in Australia,namely,general practice management plan（GPMP）and team care arrangements（TCAs）.Compared with the management of chronic diseases in China,it is suggested that China should improve the quality of general practice team,choose the chronic disease management mode according to local conditions,develop "Internet +" technology to provide technical support for chronic disease management,so as to constantly explore the chronic disease management mode that is in line with domestic conditions.