全科医疗实践中血管健康管理路径的构建与应用研究

为进一步规范血管健康管理,发挥全科医疗在健康管理中的优势,为有血管健康问题的人群提供程序化综合管理模式,浙江大学医学院附属邵逸夫医院应用全科医学理念与方法制定了血管健康整体服务计划,构建了血管健康管理路径,建立了全科医疗与健康管理的闭环式管理模式,并提供程序化的干预管理,从而保证有血管健康问题的人群能够得到最佳照护,减少其血管病变并发症的发生。实践表明,通过在全科医疗实践中构建和实施血管健康管理路径,可以促进血管健康的有效管理,提升全科医疗服务质量。本文主要介绍了血管健康管理路径的团队组织构成和实施步骤,主要路径包括筛选对象与建立档案、分层评估与制定方案、干预管理与反馈修正;同时结合实践经验,分析了构建血管健康管理路径的条件和关键点,希望可以为各地区制定血管健康管理模式提供参考。

Construction of the health management path of blood vessel and its application in general practice

In order to further standardize the health management of blood vessel and give full play to the advantages of general practice in health promotion,Sir Run Run Shaw Hospital of Zhejiang University School of Medicine formulated a integrated health service plan of blood vessel according to the concept and methods of general practice.To provide a programmatic and comprehensive management model for patients with vascular health problems,a health management path of blood vessel was constructed.A closed-loop management model of medical treatment and health promotion in general practice was established with programmatic intervention methods to ensure that patients with vascular problems could obtain the best care and reduce the occurrence of vascular disease complications.It proved that constructing and implementing a vascular health management path in general practice could promote effective management of vascular problems and improve the quality of medical services.This paper mainly introduced the team organization structure and implementation steps of the vascular health management path mainly,including the screening of objects and establishment of files,hierarchical evaluation of patients and formulation of medical plans,and intervention management and corrections based on feedback.At the same time,combined with practical experience,the conditions and key points of the construction of the vascular health management path was analyzed with a view to providing a reference for the development of the vascular health management models in other regions.