安徽省卫生服务体系整合结构和有效性研究——以马鞍山市、肥西县和肥东县为例

目的:通过对安徽省三县市卫生服务体系整合结构和有效性的研究,为促进卫生服务体系整合提供政策建议。方法:采用典型抽样,对安徽省马鞍山市、肥西县和肥东县卫生服务体系进行案例分析。数据主要来源于机构调查问卷、医生和患者调查问卷和机构关键知情人访谈。定量和定性数据分析相结合,采用社会网络分析方法分析体系整合结构和有效性。结果:马鞍山市卫生服务体系结构的整合度最高,其次是肥西县,肥东县最低。体系有效性与结构整合程度一致。三县市的卫生服务体系在整合方面均存在优势和不足。结论:卫生服务体系整合效果是各体系内外环境综合作用的产物。马鞍山市的市立医疗集团改革和肥西县的县乡医联体改革在整合卫生服务体系结构的同时对卫生服务体系的有效性产生了积极影响。     

城乡卫生服务体系纵向整合阻碍因素及指标框架构建

纵向整合已成为弥合断裂的城乡卫生服务体系的必要选择。然而,诸多因素阻碍着纵向整合实践,系统地梳理和归纳阻碍因素将有利于纵向整合实践。文章通过借助卫生系统宏观模型作为理论框架,采用演绎列举方式收集了城乡卫生服务体系纵向整合的阻碍因素指标及其框架构建,旨在为我国城乡卫生服务体系纵向整合提供一些参考。     

潍坊市基本医疗卫生服务可得性建设的主要做法

建立健全基本医疗卫生服务体系是＂人人享有基本医疗卫生服务＂的前提与保障。本文通过分析总结潍坊市在基层卫生机构建设管理方面的经验,提出了整合资源发展基层卫生机构、调整结构建设达标服务体系、加强培训提升人员服务能力、制定惠民利民政策和提高卫生服务可得性的讨论与参考。     

我国卫生健康服务体系的建设、成效与展望

文章首先全面回顾了新中国成立70年来我国卫生健康服务体系的建设历程,从资源数量增加和质量水平提高、公平性与可及性增强、服务体系结构优化、服务能力和服务效率提升、群众健康水平改善等方面介绍了我国卫生健康服务体系建设取得的显著成效。从健康需求的增长和变化、发展不平衡不充分以及仍需进一步深化体制机制改革等方面分析了我国卫生健康服务体系建设面临的新形势与新挑战,从四个方面提出了推动优质高效、协同整合的新型卫生健康服务体系建设和发展的建议。     

整合保健：英国经验对我国社区卫生服务改革的启示

在对英国卫生保健体系进行梳理的基础上,总结了其开展整合保健的做法和经验,尤其是近年来英国卫生服务与社会服务体系进行整合的趋势值得我国借鉴。本文受英国卫生保健体系尤其是初级卫生保健整合做法的启发,针对我国社区卫生服务改革中存在的问题,提出相关的政策建议,包括加强多学科服务团队建设,推动医学模式在社区转变;建立＂守门人＂制度,做实社区首诊和双向转诊;建立部门间的沟通机制,整合卫生服务与社会服务;加大舆论宣传力度,引导居民就医需求等。     

建设以人为本的卫生服务体系

为满足居民健康需求,我国卫生服务体系需要不断做出改革和调整。健康需要、公平和效率、服务质量、卫生服务体系的发展历史和现状是体系建设需要考虑的四个维度。本文认为建设以人为本的卫生服务体系是方向,并从人文关怀、利益相关、基层为本、连续整合和条件支撑五个方面对其内涵进行了阐述。提出了提升基层卫生服务质量、整合卫生服务体系和强化政府责任等建设以人为本卫生服务体系的策略和路径。     

我国城乡卫生服务体系纵向整合的路径依赖研究

我国长期的二元化社会导致了城乡间医疗卫生服务体系"碎片化"以及城乡间医疗服务的"非连续性",整合城乡医疗卫生服务体系已经迫在眉睫。本研究通过对我国城乡卫生体制变迁过程中的路径依赖特征与锁定效应进行分析,旨在为城乡医疗卫生服务体系的纵向整合实践提供科学参考依据。     

加拿大健康服务整合:实践与启示

系统梳理了近年来有关加拿大卫生服务整合的文献和政策文件,归纳了安大略省、阿尔伯塔省和魁北克省的卫生服务整合实践及方式,包括卫生组织机构间整合、卫生服务团队整合以及一系列卫生服务整合,并总结组织机构间整合的促成因素和阻碍因素以及具体的整合策略。结合中国实际,提出我国在推进卫生服务整合过程中应坚持以政府为主导,充分发挥市场机制的积极作用,通过基层卫生服务的网络式管理与组团式服务,将重点人群和特定疾病的卫生服务整合视为战略重点,发挥护士在卫生服务整合中的助推作用,建设有利于整合的卫生信息系统,不断推进分级诊疗并弥合割裂的卫生服务体系,为居民提供个性化、方便、综合、连续的整合型卫生服务。     

我国卫生服务体系的调整与改革

卫生服务体系、医疗保障体系和卫生执法监督体系构成了我国比较完整的卫生体系。我国卫生服务体系是建国以后在计划经济体制下建立和发展起来的。我国卫生服务体系改革与发展的思路,应以有效性和经济性作为标准,评价我国卫生服务体系的利弊。对我国现有的卫生服务体系进行调整与改革,构建一个更加有效、经济的卫生服务体系。卫生服务体系的调整与改革能否顺利进行,关键是改革卫生管理体制,实施区域卫生规划。     

整合视角下基层卫生服务体系现状与制度安排思考

本文从整合的理念出发,对我国基层医疗卫生服务体系中存在的组织机构和任务欠缺协同性、促进体系整合的配套政策缺位、卫生服务模式提供缺乏整合性、规划先行对于卫生服务体系整合没有发挥引导和调节作用等诸多硬性和软性方面的问题进行分析,并提出了制度安排在注重卫生服务体系硬性和软性整合若干方面的协同性、注重规划对于卫生服务体系整合的作用以及基于卫生服务体系整合状态下的基本药物制度实施设想。     

整合医疗：中国医改的战略选择

本文从理论、国际经验和趋势,以及中国现状,阐述整合医疗在医疗卫生改革中的重要性和作用。建议将整合医疗作为中国医改的战略选择,大力整合医疗卫生体系,建立公立医院之间、公立医院与城乡基层医疗卫生机构的分工协作机制,恢复三级医疗卫生网络,实行分级医疗、双向转诊的医疗服务模式,从根本上改变目前医疗卫生体系分割的局面,提高医疗卫生资源的利用效率,切实缓解群众＂看病难、看病贵＂的问题。     

The integration of public health and medicine

President Clinton's American Health Security Act proposes to reform and integrate the medical care and public health service delivery systems. Historically, there have been examples of efforts to integrate public health and medical activities. Yet, while many have acknowledged the inherent value of such an integrated approach to improving health, the fact is that these efforts have had only limited success. The "new deal" President Clinton has proposed for these health institutions is examined in this context. If the notion of integration is taken seriously--that is to mean the extent to which each system's diverse activities complement each other, fitting together to form an integrated whole--then it will not be easy to achieve. Review of the "visions" of public health and medicine and of examples of efforts to integrate public health and medicine in this country suggest five conditions that must be met if successful integration is to be achieved. While the resources necessary to integrate public health and medicine are great, of equal importance is the acceptance of a shared vision of an integrated health care system, and of the respective roles and responsibilities of public health and medical care in that system. The benefits to our nation's health of proceeding in this way, however, are enormous. As we move into the twenty-first century, an integrated system of public health and medical care services is our nation's best hope for not only improving the health of all our citizens, but for closing the "health gap" between socioeconomically disadvantaged groups and the rest of the population.     

Payment incentives and integrated care delivery: levers for health system reform and cost containment

The Patient Protection and Affordable Care Act encourages use of payment methods and incentives to promote integrated care delivery models including patient-centered medical homes, accountable care organizations, and primary care and behavioral health integration. These models rely on interdisciplinary provider teams to coordinate patient care; health information and other technologies to assure, monitor, and assess quality, and payment and financial incentives such as bundling, pay-for-performance, and gain-sharing to encourage value-based health care. In this paper, we review evidence about integrated care delivery, payment methods, and financial incentives to improve value in health care purchasing, and address how these approaches can be used to advance health system change.     

Integrated delivery systems in California--success and failure determining factors for the first 10 years and impetus for Germany

Since the coming into effect of the Health Care Modernization Act (Gesundheitsmodernisierungsgesetz) the conditions for integrated health care delivery are favourable in Germany. However, comprehensive approaches are a long time in coming. In contrast, integrated health care delivery as an integral part of the spreading of managed care entered a further stage of development, which enables health care decision makers to draw conclusions regarding the further development of integrated health care delivery in Germany. Based on case studies integrated delivery systems in the San Francisco Bay Area have been analyzed with the objective to evaluate pitfalls and successful strategies for integrated health care delivery. The major pitfalls refer to an insufficient local focus, a lack of actual integration and the application of per capita reimbursement (which is a key subject on the political agenda in Germany as well) within integrated delivery systems. On the contrary, successful strategies include achieving a dynamic tension between centralized and decentralized coordination, internal and external relationship management, well organised human resource management including a well-defined corporate policy and a comprehensive implementation of information technology. Based on US experiences with integrated delivery systems implications for the design of integrated health care delivery in Germany are discussed.     

我国乡村卫生一体化管理模式与比较

通过剖析乡村卫生一体化管理的内涵和政策目标,将其归纳出乡村卫生组织一体化和乡村卫生服务一体化两种模式;对两种模式的推进障碍因素和优劣进行了比较;提出新医改政策背景下推进乡村卫生服务一体化的建议是：分步分类推进、把连续的卫生服务作为一体化管理的落脚点、由国家层面建立乡村两级卫生服务规范“管理包”,以及县级卫生行政部门要积极发挥主动作用。     

基层卫生服务整合模式的探索——以广州市南沙区为例

发展整合卫生服务已成为我国医改的战略性选择,广州市南沙区以整合卫生服务理论为指导,以“人人享有基本医疗”为目标进行了一系列改革,包括管理体制的改革、镇（街）村两级卫生机构的整合、人力资源的整合、信息的整合、村卫生室的标准化建设和各项卫生政策的组合运用,改善了卫生服务的公平性、可及性,提高了基层卫生资源的利用效率,充分体现了基层卫生服务的公益性属性。在构建农村基层卫生服务整合模式方面做了有益的探索,该经验可以进一步推广。     

基层医疗卫生服务整合的国际经验及对我国的启示

目的:总结典型国家基层卫生服务提供中实现医防整合的经验,为我国基层医疗卫生服务整合提供借鉴。方法:本研究方法为文献研究。结果:在个人层面,英国、泰国、古巴培养全科医生作为"守门人"并将其作为提供医防整合服务的主体;在机构层面,各国基层机构组成服务网络,内部强调跨学科合作;在体系层面,通过横向合作和有序的首诊与转诊协调服务;国家立法保障和健康保险筹资等引导支持基层医疗卫生服务整合。结论:培养和配置高质量的医防一体的全科医生、促进机构跨学科融合、通过立法和筹资体系予以保障是各国提供基层整合型服务的核心,值得我国基层医防服务整合借鉴。     

Conceptualizing and measuring integration: findings from the health systems integration study

Given the pressures for health care reform, interest in the concept of integrated or organized delivery systems as a means to offer more coordinated cost-effective care is growing. This article has two primary objectives: (1) to clarify the different types of integration associated with the notion of an organized delivery system, and (2) to share the results from an ongoing study of 12 organized delivery systems. The findings indicate a moderate level of integration overall, particularly in the areas of culture, financial planning, and strategic planning. The study found that corporate staff respondents perceive their systems to be more integrated and effective than do operating unit managers, and that some functional integration areas are positively associated with both physician-system and clinical integration that, in turn, are positively related to each other. Overall, perceived integration was found to be positively associated with perceived effectiveness.     

Measuring key integration outcomes: a case study of a large urban health center

BACKGROUND: Health care reform, through innovative health delivery systems, has been a high priority to address staff shortages, increasingly complex care needs of the aging population, and fragmentation of care. Community health centers have been promoted as one service delivery model with large potential for integration and collaboration. The South Calgary Health Centre (SCHC) opened in June 2004 with the mandate to provide a new model for accessible, accountable, integrated, and community-based health services. PURPOSE: The primary objective was to determine the performance of the SCHC; and further, to establish the value of the evaluation framework used in measuring organizational performance of an integrated service delivery model. METHODOLOGY: Multiple stakeholders were involved in the evaluation in a utilization-focused, participatory way. A comprehensive evaluation framework was developed and implemented to assess the performance of the SCHC at system, provider, and patient levels. Functional, clinical, and community integration were key systems outcomes within this framework. Case-study methodology with mixed methods drawing on multiple data sources (both qualitative and quantitative) was used. FINDINGS: The evaluation findings suggest that the center is functioning well and that staff and client satisfaction are high. Although the model has not achieved all that was originally intended (i.e., fully realized clinical integration), participants felt that the model has been successful and has great potential for integration. The comprehensive evaluation framework developed for this project proved useful in assessing different aspects of integration as well as provider and client perceptions of the center's performance. PRACTICE IMPLICATIONS: Evaluation findings and recommendations have been used to inform operations at the SCHC and for the planning of future health centers. The evaluation framework may help to standardize evaluation approaches across projects and can be used for monitoring progress of the SCHC as well as future evaluations of integrated service delivery models.     

Organizing mental health services: an evidence-based approach

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.