以全科医师为主体社区健康服务为中心的高血压管理模式探索

目的探索构建以全科医师为主体、社区健康服务为中心无缝融合的高血压等社区慢性病管理模式，以便能够为社区高血压慢性病控制提供决策和实施依据。方法以成都市成华区万年社区卫生服务中心归属的社区内已经确诊为高血压疾病的患者为服务对象，制定血压及相关并发症为指标，实施以全科医师为主体的社区健康服务中心的高血压等慢性病管理模式，并比较管理模式实施前后的相关指标。结果社区内高血压患者经过系统的、规范的、科学的管理后，发生不良行为习惯的人数大大降低，血压情况得到了有效的控制，并且明显的改善了患者的各项指标，管理实施具有积极的意义。结论以全科医师为主体社区健康服务中心的高血压等慢性病管理模式是一种新型的高血压疾病管理模式，提高了高血压患者的生存质量，合理有效的利用了社区医院的医疗资源，降低了患者的治疗费用，非常值得推广。

Model exploration about general practitioners as the main body community health service center for hypertension management

Objective To explore constructing the theme of general practitioners, community health service center for seamless integration of hypertension and other chronic disease management model, for providing decision-making and implementation of chronic disease control. Methods Patients with hypertension had been diagnosed of the health service centers of community in Chengdu Chenghua Wannian community as a target, to develop an indicator of blood pressure and related complications, implementation of chronic disease management in community health service centers was done by general practitioners as the main body, and the relevant indicators management model before and after implementation were compared. Results The number of occurrence of bad habits hypertensive patients in the community through the system, standardized and scientific management greatly reduced, blood pressure had been effectively controlled, and significant improvemented in the indicators of patients with active management implementation significance. Conclusion General practitioners as the main community health service centers for hypertension, chronic disease management model is a new type of hypertension disease management model, which improves the quality of life of patients with hypertension, rational and effective use of medical resources community hospitals, reducing the cost of treatment of the patient, very worthy of promotion.