三级医院-社区卫生一体化管理慢性病综合干预模式探讨

目的 探索三级医院-社区卫生一体化管理慢性病综合干预模式.方法 江苏盛泽医院建立三级医院-社区卫生一体化管理慢性病综合干预模式,组建慢性病综合干预三级体系及慢性病管理服务团队,积极开展慢性病的社区综合干预.结果 健康知识知晓率、健康行为形成率分别由干预前的46.17%和38.25%上升至85.45%和82.13%,有显著差异(P＜0.01).高血压病的管理率、控制率分别由干预前的51.99%和40.90%上升至92.07%和64.94%;糖尿病和冠心病的管理率、控制率有显著提升.干预前后均有很大程度的提高(P＜0.01).结论 三级医院-社区卫生一体化管理社区慢性病综合干预模式,促进了社区居民健康教育与健康促进活动,提高慢性病患者的管理率、控制率,具有重要示范和推广意义.

A Discussion on Comprehensive Intervention of Chronicle Disease under Third-Grade-Hospital-Community Health Integrated Management Mode

Objective To explore comprehensive intervention of chronicle disease under Third-Grade-Hospital-Community Health Integrated Management Mode.Methods Jiangsu Shengze Hospital explored comprehensive intervention of chronicle disease under Third-Grade-Hospital-Community Health Integrated Management Mode by establishing the Three-Level Chronicle Disease Comprehensive Intervention System and Chronicle Disease Management and Service Team,thereby developing the community′s comprehensive intervention of chronicle disease.Results The health-related-knowledge awareness rate and healthy-behavior formation rate have shown significant change(P<0.01),increased from 46.17% and 38.25% to 85.45% and 82.13% respectively,as compared to pre-intervention data.Management rate and control rate of high blood pressure improved from 51.99% and 40.90% pre-intervention to the current 92.07% and 64.94%;Management rate and control rate of diabetes and coronary heart disease improved.All data have shown significant differences(P<0.01) post-intervention.Conclusion Establishing comprehensive intervention of chronicle disease under Third-Grade-Hospital-Community Health Integrated Management Mode,reinforcing health education and promotion of community residents and raising the management and control rate of chronicle disease patients are entirely feasible.They serve as important exemplifications and are worthy of popularizing.