我国基于团队协作的社区慢性病管理研究的分析

目的：了解我国慢性病管理实施现状，探索团队协作管理社区慢性病的改进方法。方法：利用关键词检索中国学术期刊网全文数据库、PubMed等常用中英文数据库，收集2008年1月至2013年12月公开发表的我国社区慢性病管理的研究报道，结合一定的纳入和排除标准，进行严格文献筛选；并基于慢性病团队协作管理模式对最后得出的文献进行归纳分析。结果：经系统检索后共得到698篇文献，进一步筛选得到33篇符合纳入标准的文献。在基于慢性病团队协作管理模式的几大要素中，全部文献涉及对慢性病患者的自我管理支持，但仅9篇提及团队成员之间的交流，11篇文献提及有明确的团队分工。结论：我国的社区慢性病管理工作存在不足，应建立一支真正意义上的全科服务团队，明确团队成员的角色与职责，提高团队成员的服务能力，同时应注意为患者提供多种形式的自我管理支持服务。

A brief review of research on chronic disease management based on collaborative care model in China

Objective: To evaluate the situation for chronic disease management in China, and to seek themethod for improving the collaborative management for chronic diseases in community.Methods: We searched literature between January 2008 and November 2013 from the Database,such as China Academic Journal Full-Text Database, and PubMed. The screening was strictly inaccordance with the inclusion and exclusion criteria and a summary was made among the selectedliterature based on a collaboration model.Results: We got 698 articles after rough screen and finally selected 33. All studies were involved inpatient’s self-management support, but only 9 studies mentioned the communication within the team,and 11 showed a clear team division of labor.Conclusion: Chronic disease community management in China displays some disadvantages.It really needs a general service team with clear roles and responsibilities for team members toimprove the service ability of team members and provide patients with various forms of selfmanagementservices.