Connotation of the community health management models of chronic non-communicable diseases and its revelations to our country
-
摘要: 随着我国人口老龄化进程的加快以及慢性非传染性疾病患病率的不断上升,如何在社区对慢性非传染性疾病展开更精准有效的管理关乎我国人口健康和社会发展。本研究就慢性非传染性疾病社区健康管理的背景与发展,系统阐述其内涵、原则及方法,总结国内外慢性非传染性疾病社区健康管理模式,并分析我国存在的不足和相关改进措施,探究我国慢性非传染性疾病社区健康管理的未来发展方向。目前我国慢性非传染性疾病社区健康管理仍处于初期探索阶段,主要模式包括家庭医生签约服务模式、医院-社区-家庭联动模式与医养结合模式。相比之下,国外慢性非传染性疾病社区健康管理理念起步更早,创立了诸如美国糖尿病预防计划、澳大利亚新南威尔士州慢性病预防管理模式、创新型慢性病照护框架等一系列各具特色、行之有效的社区慢性病管理模式。上述管理模式对我国有一定的借鉴意义,包括:系统高效地整合资源;根据社区人群的特点制定慢性病管理计划;注重居民的自我健康管理意识。目前,我国慢性非传染性疾病控制体系已取得明显进步,但依然存在着医疗资源配置结构性失衡和低效率、分级诊疗制度尚未完善、人群自我健康管理意识和能力欠缺等问题。未来仍需深入开展针对性的慢性病健康教育,建立人才培养长效沟通机制,完善以家庭为单位的分级诊疗制度。Abstract: With the acceleration of the aging process of the Chinese population and the rising prevalence of chronic non-communicable diseases, a strategy for the accurate and effective management of chronic non-communicable diseases in community health service centres is crucial for health and social development of the Chinese population. Based on the background and development of community health management of chronic non-communicable diseases, this study systematically discusses the connotation, principles and methods of community health management of chronic non-communicable diseases, summarises foreign and domestic community health management models for chronic non-communicable diseases, analyses the shortcomings and relevant improvement measures in China, and explores the future development direction of community health management of chronic non-communicable diseases in China. Nowadays, community health management of chronic non-communicable diseases in China still lacks progress. Domestic management models include the family-doctor contract service model, hospital-community-family linkage model and medical-care combination model. By contrast, the concept of community health management of chronic non-communicable diseases in foreign countries is proposed earlier, and a series of distinctive and practical models, such as the National Diabetes Prevention Program, New South Wales Chronic Disease Prevention and Management Model in Australia and Innovative Care for Chronic Conditions Framework, has been developed. The above management model has certain reference significance for our country, including the systematic and efficient integration of resources, formulation of chronic disease management plans based on the characteristics of specific communities and a focus on residents ' awareness of self-health management. At present, China ' s chronic non-communicable disease control system has made significant progress, but there are still problems such as structural imbalance and low efficiency of medical resource allocation, imperfect hierarchical diagnosis and treatment system, and lack of awareness and ability of self-health management of the population. In the future, it is still necessary to carry out targeted health education on chronic diseases, establish a long-term communication mechanism for talent training, and improve the hierarchical diagnosis and treatment system based on families.
-
Key words:
- Community /
- Health management /
- Chronic disease /
- Health intervention /
- Health risk evaluation
-
[1] 刘杨, 王凯, 肖革新, 等. "全科医学+"紧密型医共体下慢性病管理模式构建研究: 基于国际慢性病管理模式和经验[J]. 中国全科医学, 2022, 25(16): 1923-1928. doi: 10.12114/j.issn.1007-9572.2022.0061 [2] 张敏, 肖月, 袁静, 等. 我国慢性病社区健康管理现状研究[J]. 成都医学院学报, 2019, 14(5): 650-653, 657. doi: 10.3969/j.issn.1674-2257.2019.05.021 [3] 周光清, 夏瑶, 崔华欠, 等. 我国城市社区健康管理的问题与对策研究[J]. 中国全科医学, 2018, 21(7): 852-855. doi: 10.3969/j.issn.1007-9572.2018.07.020 [4] 中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2020概要[J]. 中国循环杂志, 2021, 36(6): 521-545. doi: 10.3969/j.issn.1000-3614.2021.06.001 [5] 谢有彩, 陈惜琴, 郭桂枝. 以人为中心的主动健康管理服务在社区慢性病患者中应用效果观察[J]. 医学理论与实践, 2020, 33(12): 2052-2053. https://www.cnki.com.cn/Article/CJFDTOTAL-YXLL202012091.htm [6] 方嘉列, 陈婉莉, 王静雅, 等. 基于健康信念模型(HBM)的社区冠心病患者遵医行为影响因素的横断面研究[J]. 复旦学报(医学版), 2020, 47(3): 378-384, 391. doi: 10.3969/j.issn.1672-8467.2020.03.011 [7] 刘彩, 王晓方, 李莹, 等. 健康信念模型演进与应用的可视化文献分析[J]. 中国健康教育, 2020, 36(2): 167-170. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGJK202002017.htm [8] 张伟. 构建全生命周期的新时代中国特色健康服务模式[J]. 中国循证医学杂志, 2019, 19(12): 1379-1387. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZXZ201912002.htm [9] 陈大方. 疾病防控新理念: 精准健康管理[J]. 中国慢性病预防与控制, 2020, 28(2): 81-84. https://www.cnki.com.cn/Article/CJFDTOTAL-ZMXB202002001.htm [10] 陈家应, 胡丹. 医防融合: 内涵, 障碍与对策[J]. 卫生经济研究, 2021, 38(8): 3-5, 10. https://www.cnki.com.cn/Article/CJFDTOTAL-WSJJ202108002.htm [11] 武轶群, 胡永华, 陈大方. 健康大数据在精准健康风险评估中的应用[J]. 中国慢性病预防与控制, 2020, 28(3): 226-229. https://www.cnki.com.cn/Article/CJFDTOTAL-ZMXB202003019.htm [12] 王梓懿, 刘丽杭. 家庭医生签约服务: 治理困境与机制构建[J]. 中国卫生政策研究, 2019, 12(6): 63-68. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWZ201906014.htm [13] 贺焜, 方海. 中国居民对家庭医生签约服务内容的偏好研究: 基于离散选择实验[J]. 中国卫生政策研究, 2020, 13(2): 61-66. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWZ202002009.htm [14] 吕韵, 景日泽, 王德猛, 等. 家庭医生签约服务的激励机制内涵分析: 基于厦门市"三师共管"模式[J]. 中国全科医学, 2021, 24(16): 1995-2002. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX202116002.htm [15] 孙丽, 顾海燕, 高红, 等. 医院社区家庭联动管理方案在骨质疏松性椎体骨折病人二级预防中的应用研究[J]. 护理研究, 2021, 35(20): 3622-3626. https://www.cnki.com.cn/Article/CJFDTOTAL-SXHZ202120010.htm [16] 高爽, 杨陆, 彭涛. 国外医养结合养老模式研究进展[J]. 护理学杂志, 2021, 36(3): 17-20. https://www.cnki.com.cn/Article/CJFDTOTAL-HLXZ202103007.htm [17] 胡善菊, 张琪蒙, 赵李洋, 等. 社区卫生机构参与医养结合的SWOT条件分析[J]. 中国老年学杂志, 2021, 41(13): 2891-2895. https://www.cnki.com.cn/Article/CJFDTOTAL-ZLXZ202113060.htm [18] 郑研辉, 郝晓宁. 社区医养结合服务模式比较研究[J]. 兰州学刊, 2021, 1(1): 201-208. https://www.cnki.com.cn/Article/CJFDTOTAL-LZXK202101015.htm [19] 高原, 寇现娟. 体医融合背景下的糖尿病防治: 美国经验及启示[J]. 中国全科医学, 2022, 25(25): 3089-3096. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX202225019.htm [20] PEIRIS D, WRIGHT L, NEWS M, et al. Community-based chronic disease prevention and management for aboriginal people in New South Wales, Australia: Mixed methods evaluation of the 1 deadly step program[J]. JMIR Mhealth Uhealth, 2019, 7(10): e14259. DOI: 10.2196/14259. [21] 李进, 张海燕, 杨佳. 国内外经典慢性病管理模式对我国农村地区慢性病管理的启示[J]. 中国全科医学, 2022, 25(16): 1935-1941. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX202216003.htm [22] 王丽敏, 陈志华, 张梅, 等. 中国老年人群慢性病患病状况和疾病负担研究[J]. 中华流行病学杂志, 2019, 40(3): 277-283. [23] 庞瑞芝, 李帅娜. 我国医疗资源配置结构性失衡与"看病贵": 基于分级诊疗体系的视角[J]. 当代经济科学, 2022, 44(3): 97-110. https://www.cnki.com.cn/Article/CJFDTOTAL-DJKX202203008.htm [24] 熊智. 我国慢性病防治面临的挑战与对策[J]. 中国慢性病预防与控制, 2019, 27(9): 720. https://www.cnki.com.cn/Article/CJFDTOTAL-ZMXB201909024.htm [25] 黄传应, 杨荣, 廖晓阳. 家庭社会支持对高血压治疗依从性影响的研究进展[J]. 中华全科医学, 2021, 19(3): 466-470. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202103037.htm [26] 黄文博, 冯娴, 姚元龙, 等. 全科医学视角下我国高血压患者的自我管理[J]. 中华全科医学, 2022, 20(7): 1085-1088. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202207001.htm [27] 姜媛媛, 王晶晶, 张伟宏, 等. "互联网+"在慢性病管理中的应用研究进展[J]. 现代医药卫生, 2019, 35(5): 692-695. https://www.cnki.com.cn/Article/CJFDTOTAL-XYWS201905018.htm
点击查看大图
计量
- 文章访问数: 650
- HTML全文浏览量: 150
- PDF下载量: 82
- 被引次数: 0