整体医疗实践与探讨

随着生物医学模式向生理——心理——社会医学模式的转变和“以病人为中心”办院宗旨的确立,要求医院应转变医疗观念,开展整体医疗,为病人提供适应现代医学模式、全过程、全方位、高质量、高效率、低消耗的服务。现就医院开展整体医疗问题探讨如下: 1 整体医疗的提出与概念 1.1 整体医疗的提出 整体医疗是为适应医学科学的进     

整体医疗初探

为适应生物-心理-社会医学模式的要求,本提出了医院应转变医疗观念,开展整体医疗,为病人提供全过程、全方位、高质量、高效率、低消耗的服务。并对整体医疗的概念、特点、实施方法与内容进行了探讨。     

以服务优势提升医院竞争力

随着服务经济时代的来临,医院传统的医疗服务模式正面临着前所未有的竞争和挑战。在医疗市场激烈竞争的状态下,医院的服务水平与品质在一定程度上被提到了与医疗技术相同的地位加以研究和探讨。针对病人的就医心理,提供优质的医疗服务,满足不同的医疗需求,进一步提高病人满意度,创造服务的竞争优势,已经成为现代医院管理者所面临的不容忽视的议题。     

转变医疗服务模式,充分发挥医生的作用

在社会主义市场经济体制下,随着医学模式由单纯的生物医学模式向生物—心理—社会的综合模式转变,病员对医疗服务提出了新的需求,这迫使医疗服务模式由以疾病为中心的服务模式向以病人为中心的服务模式转变。本文分析了医生在适应这一转变中存在的问题,并提出了相应的对策。     

以病人为中心改革门诊工作

以病人为中心深化医院改革是医院工作的宗旨,是适应市场经济、适应医院模式转变的需要。几十年的医院管理一直遵循以病为本,把病人当成单纯的求医者。目前世界医学模式转变已从单纯生物学医疗转向生物医疗与社会、心理医疗综合模式,服务模式也必须相适应而转变。可是服务模式的转换与医学模式的转换相比要慢得多,所以要改变过去只注重以疾病为中心为强调以病人为中心,在给病人提供医疗服务的同时,提供一些社会、心理服务,使病人感受到自己被医院所尊重,自己的权利被认可。遵循这一原则,黑龙江省医院门诊部从改革急诊急救入手,实现优质服务与环境改造配套的全方位整体改革。     

浅谈医疗服务价格

医疗服务价格必须经国家有关部门按照分级管理权限和审批程序有计划地制定 ,医疗单位没有制定医疗价格的自主权。由于医疗服务价格改革相对滞后 ,医疗服务价格与成本背离。1.护理成本与护理收费以一级护理为例 ,除护理常规外 ,还要严密观察病情变化 ,每15～30分钟要巡视病人一次 ,要定时测量体温、脉搏、呼吸、血压 ,要根据病情制订护理计划 ,并要做好护理记录等 ,而规定的收费标准是每天每床5元 ,远远低于护士的人力成本。随着医学模式的转变 ,以疾病为中心的功能护理模式逐渐被以人为中心的整体护理模式所替代 ,床位与护士比相应地从1∶0.…     

医院整体医疗管理模式探索历程与实施成效

医院整体医疗管理模式是以医学整体论、生物—心理—社会医学模式为指导,为满足社会民众的健康需求而创新的医院医疗管理新模式.经过10多年的实践与探索,拓宽了院前院后医疗保健功能,提升了医疗质量与医疗服务效能,融洽了医患关系,为医院赢得了良好的声誉,成效显著.     

以病人为中心 提高门诊医疗服务质量

门诊的医疗服务质量不仅取决于医疗技术水平，而且还取决于病人及家属在门诊就医过程中的直接感受和主观评价，“以病人为中心”的现代服务模式，不仅治疗病人的疾病，而且满足病人在门诊就医过程中的其他需求，如方便、快捷、安全、舒适等心理需求和感受。文章介绍了绍兴市人民医院门诊近几年来坚持以病人为中心的一些具体做法。     

临床路径的特点与应用

基于文献回顾认为国外临床路径研究与应用处于成熟阶段。临床路径作为新的管理模式主要特点为：(1)医疗模式转变。由现行的多个部门面向病人的部门性医疗服务模式向由多个部门共同面向病人的整体医疗服务模式转变。(2)采取具有医疗、护理、药师、医技、营养以及管理专业等人员的团队的个案管理与个案管理人方式。(3)突出诊疗标准的实施性。(4)实现病案记录的整体化、规范化和信息共享化。(5)引入病人参与机制。并就应用临床路径的基本条件、实施步骤等进行了讨论。     

新型医学模式下如何坚持以病人为中心进一步提高医院服务质量探讨

所谓新型医学模式是指“生物-心理-社会医学模式”，其进步性在于医疗服务既治疗病人躯体疾病，又要调整病人的心理状态．并让其健康回归社会，回归自然。如何在这种模式下牢固坚持“以病人为中心”的服务理念，为病人提供更加“温馨、便捷、优质”的服务，是值得我们共同探讨的新课题。     

适合社区的“医养结合”新养老模式探索

人口老龄化进程的加速,老年患病比例的增加,就医质量需求的增长,让如何养老成为了当今重要的热点社会问题。传统的养老方式无法满足现有的养老需求,促使新型养老模式应运而生。新养老模式“医养结合”的提出,已经得到各方面的积极响应。但养老机构医疗服务能力较弱、专业人才短缺,医养服务质量低、社区卫生服务中心的利用率不高、政策细则不完善、法律法规不健全等问题仍是医养结合养老模式发展面临的巨大问题和困难。该文在此基础上提出建议,构建多层次的“医养结合”服务体系、多层次专业人员培养模式,加快养老服务护理人才队伍建设、改革医疗保险方式,健全护理保险体系、完善相关法律规范,提高政策执行效率,以促进“医养结合”养老模式的迅速发展。     

城市老年人医养结合服务需求及其影响因素分析

目的:探讨城市老年人医养结合服务需求的现状及其影响因素。方法:采用两阶段随机抽样的方法,运用“城市老年人医养结合服务需求量表”对南京市440名城市老年人进行抽样调查。结果:城市老年人的医养结合服务需求水平比较高(3.7475±0.31499);年龄、性别、收入水平和健康状况是城市老年人医养结合服务需求的影响因素(P<0.05),年龄比较大、收入水平比较高、健康状况比较差的男性城市老年人的医养结合服务需求最高。结论:积极推进医养结合服务供给侧结构性改革,面向全体老年人提供有针对性的、多元化的医养结合服务。     

基于“市民一卡通”自助医疗服务系统的研究与应用

目的：探讨基于“市民一卡通”诊疗模式在医院诊疗服务中所发挥的作用。方法：以信息技术为手段,以医疗“一卡通”的应用为基础,构建支持患者的自助式服务的集成应用系统。结果：患者在自助服务终端上轻松地完成挂号、交费、预约专家、查询和打印报告单等就诊流程。结论：基于“市民一卡通”自助医疗服务系统优化了患者就诊流程,改善了就医环境,有效节约了就诊时间,提高了医院的医疗效率和服务水平;依托区域卫生信息平台,更好地发挥了区域医疗信息资源的协同应用。     

论医学院校分析测试中心的内涵建设

针对医学院校分析测试中心的实际运行情况,提出了"教学、科研和服务为一体的发展模式"。在实现大型分析测试仪器设备资源共享和为社会服务的前提下,提高分析测试中心的优势地位和主导功能。     

Sharing a Playbook: Integrated Care in Community Health Centers in the United States

Objectives. We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care.Methods. We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care.Results. More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care.Conclusions. A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.The treatment of behavioral health conditions is a key component of quality care.1 Behavioral health encompasses mental health and substance use disorders as well as health behaviors.2 Improving access to screening and treatment services for mental health and substance use disorders is critical to the success of wider efforts to improve the health care system to pursue the triple aim3 of better health, better care, and lower per-person costs.4,5 However, medical and behavioral health care providers have historically practiced in isolation, with little communication or coordination. The need to better integrate behavioral and medical care is especially pronounced for underserved patients; according to the Institute of Medicine, “[t]he single greatest flaw of the mental health safety net is its nearly total disconnection from the core [general medical] safety net.”6^(p189)Mental health and substance use disorder services are frequently provided in primary care settings; in fact, many patients with behavioral health disorders never receive care in a specialty behavioral health setting.7,8 Community health centers are key portals of access to medical and behavioral health services in underserved communities.9 Community health centers are also called “federally qualified health centers” or “health centers.” We used data from federally qualified health centers that received grant funding in 2010 under Section 330 of the Public Health Services Act through the Bureau of Primary Care at the Health Resources and Services Administration of the US Department of Health and Human Services. Because many health center patients face additional access barriers—40% of health center patients were uninsured in 2010—treatment initiation and engagement might be improved if on-site behavioral health services are available where patients access medical care and links to social services.10 The “warm handoff” to a behavioral health provider can create trust, because colocation with medical services can destigmatize behavioral health treatment. Patients already visit health centers for medical and other types of services, so accessing behavioral health services on-site at the health center is likely to be convenient.11 In addition, colocating primary care and behavioral health services is a strategy to mitigate barriers to accessing care related to cultural beliefs among patients.12Health centers are required to provide mental health and substance use disorder services on-site or by referral. Most health centers have on-site behavioral health specialists, particularly larger health centers, those located in urban areas, in the Northeast and West, in local areas with greater availability of behavioral health specialists, and in states that allow Medicaid same-day billing for medical and behavioral health services.13,14 Health center capacity is expanding under the Affordable Care Act (Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat. 855 [March 2010]) to increase access to care for underserved patients and communities.15 Improving access to behavioral health services at health centers is currently a priority; more than 1 in 3 health centers received funding to expand behavioral health capacity in 2014 of more than $105 million.16Building on the foundation of colocated behavioral health specialists and primary care providers, health centers are exploring how to integrate behavioral health services into primary care.17,18 A commonly used continuum specifies 3 basic levels of orchestration between behavioral health and medical care: coordinated from 2 separate locations, colocated in a shared space, or integrated.10,19 The definition is still evolving, but integrated care is distinguished by colocated, team-based care and, optimally, a shared care plan with both behavioral health and medical elements.10,20–23Integrated care typically refers to providing behavioral health services in the primary care setting, whereas the closely related terms “coordination” and “collaboration” are used to describe shared access to information, communication, and consultation between medical and behavioral health providers, regardless of whether the services are colocated.24,25 We examined the processes used by primary care and behavioral health clinicians in health centers to conduct evidence-based activities to improve integration: colocating medical and behavioral health services, shared access to information in patient records, joint case conferences, and joint care planning.26It is important to note that colocating medical and behavioral health services does not necessarily lead to communication and collaboration; sustained technical assistance might be needed to support providers as they make the necessary changes to cultures, structures, and processes to allow more interdisciplinary communication and collaboration.27,28 Barriers to integrated care include a lack of consensus regarding team members’ roles29,30 and interprofessional conflict stemming from differing cultural norms and mental models of practice.31 The siloed and fragmented reimbursement landscape is another factor, particularly because reimbursement is often fee for service on the basis of the volume of patient encounters; funding streams that cover provider-to-provider communication might be necessary to support integrated care.32^,33Prohibitions on same-day billing for medical and behavioral health services are another roadblock.13,34 Additional financial barriers include staffing costs and health information technology (IT) implementation costs.35 There are many other issues related to health IT, including usability issues of care coordination and registry functions, limited interoperability hindering health information exchange, and additional privacy protections for information on substance use disorders.20,36–39We explored some basic measures that can be used to assess collaboration between colocated providers and to gauge the extent to which a health center is practicing integrated care. We asked 2 main questions. First, to what extent is integrated care occurring for health center patients with behavioral health conditions? Second, which health center characteristics are associated with practicing integrated care? We hypothesized that larger health centers, those with electronic health records (EHRs), and those with higher percentages of total staffing composed of behavioral health specialists might be more likely to provide integrated care.Our study makes a unique contribution to the literature by presenting nationally representative data on the elements of integrated care for patients with behavioral health conditions in health centers. The findings on contextual and health center characteristics associated with practicing integrated care in health centers might guide policies designed to reduce unmet needs for behavioral health treatment services among underserved patients.     

县域互联网医疗应用演进与推进策略研究

县域内医疗资源配置呈“倒三角”格局,上下级医疗机构间服务协作不力,导致基层卫生机构服务能力趋弱,城乡医疗服务供需失衡,是当前基层卫生服务体系治理的客观难题。实践表明,互联网技术与医疗服务的结合能够革新医疗服务协作场景,消除医疗服务的时空限制,提升医疗资源配置效率。本研究剖析了当前互联网医疗的服务模式,提出了互联网医疗在县域的应用场景和推进策略,其核心切入点应落脚于服务协作的即时性与可及性,依托基层医生协助,构建供需双方共同参与的互联网医疗新模式。同时,通过政府主导、多主体深度协同以建立良性的县域互联网医疗应用生态,并对服务模式的技术有效性、医患可接受性、风险可控性和规模经济性四个方面展开系统评估,有序筛选适宜的模式推进。     

供给侧改革视角下的中国医改探索

2016年,我国医疗领域掀起对"医疗供给侧改革"的讨论热潮.阐述我国实施医疗供给侧改革的意义和策略;"健康中国"战略推进下我国医疗服务供给体系将面临深刻的结构性变革,供给侧改革思路将从构建能够合理分流患者的有序就医格局、以公立医院改革提高优质医疗资源服务质效、引入社会办医力量发展健康服务业三个方面入手引领中国医疗服务体系重构,同时支付制度改革引入预付制、卫生人力资源优化配置以及互联网医疗兴起都将配套医疗服务体系的供给侧改革,从而将以公立医院为主体、以疾病治疗为中心的诊疗模式转变为全面涵盖预防、体检、治疗、康复、健康管理等多环节、多流程的整合型医疗模式.     

基于典型案例的纵向整合模式下基层医疗卫生机构服务质量研究

目的:基于需方角度对纵向整合模式下的基层医疗卫生机构服务质量进行评价。方法:以北京市大兴区仁和医院和礼贤中心卫生院组成的纵向整合模式为典型案例,利用初级卫生保健质量评价工具PCAT-中文版(Primary Care Assessment Tool)对基层医疗卫生机构就诊病人采取出口调查。定量数据采用描述性统计和多元线性回归分析方法,定性数据采用主题框架分析法。结果:纵向整合模式下,该基层医疗卫生机构PCAT总得分为20.09,"首诊性"为6.59,"连续性"为3.27,"协调性"为4.58,"综合性"为5.62;三个延伸维度"以家庭为中心"为3.07,"面向社区"为1.86,"就医文化"为2.67;PCAT得分在患者就医次数和就医时间长短两个变量具有统计学意义。结论:纵向整合模式下基层医疗卫生机构的首诊性较好,连续性和三个延伸维度仍需进一步加强。未来应借助纵向整合模式的深入开展继续加强基层医疗卫生机构的服务连续性和向下转诊能力,并继续跟踪其效果。     

基于扎根理论的社区医养结合服务公私合作模式研究

目的：探讨社区医养结合服务公私合作模式的动因、策略和障碍，为我国社区医养结合服务供给侧改革提供参考。方法：运用扎根理论法，聚焦社区医养结合服务公私合作的典型案例，借助Nvivo12质化分析软件对相关主体的访谈记录及政策文本资料进行编码和分析。结果：经过开放性编码、主轴性编码及选择性编码，共得到51个初级概念、12个范畴和3个主范畴。根据扎根理论“条件-现象-行动/互动策略-结果”的典范模型，自下而上建构起社区医养结合服务公私合作的理论模型。结论：社区医养结合服务公私合作的动因包括老年人医养需求高、国家政策导向和地方政府推动；合作的策略包括建立伙伴关系、资源整合与共享、动员老年人参与；合作的障碍有体制困境、双方信任缺失、基层服务能力有限、激励不到位、公益性与趋利性的矛盾、缺少第三方监督评估。     

城乡医保统筹对农村流动人口医疗服务利用的影响——基于2017年CMDS数据的分析

目的：研究城乡医保统筹对农村流动人口医疗服务利用的影响。方法：基于2017年流动人口卫生计生动态监测调查数据(CMDS),运用线性概率模型(LPM)、非线性Logit模型和截面倍差法对研究问题进行实证分析。结果：医保制度城乡统筹能够显著提高农村流动人口利用居住地医疗服务的概率;针对不同流动范围的农村流动人口,城乡医保统筹对于市内跨县和省内跨市的群体实施效应更明显;对在非居住地参保的农村流动人口医疗服务利用影响更为显著。结论及建议：在城乡医保统筹进程中应重点关注农村流动人口这一群体,逐步提高医保制度统筹层次,渐进式消除医保制度的区域性壁垒,改善农村流动人口医保制度的福利效应。