三甲医院全程健康管理模式下的家庭医生签约服务实践

牟鈃雨; 张林; 安康; 施奕; 李才正; 佘毅; 李双庆; 苏巧俐

doi:10.16766/j.cnki.issn.1674-4152.003055

三甲医院全程健康管理模式下的家庭医生签约服务实践

doi: 10.16766/j.cnki.issn.1674-4152.003055

牟鈃雨¹,
张林¹,
安康¹,
施奕¹,
李才正¹,
佘毅^{1, 2},
李双庆^{1, 2},
苏巧俐^1, ,

1.
四川大学华西医院全科医学中心，四川成都 610041
2.
成都高新区芳草社区卫生服务中心，四川成都 610041

基金项目:

四川省科技厅项目 2020YFQ0011

四川省卫生健康委员会项目 20PJ006

详细信息

通讯作者:
苏巧俐，E-mail：2961774468@qq.com

中图分类号: R197.323.2 R192.3
计量
- 文章访问数: 204
- HTML全文浏览量: 47
- PDF下载量: 29
- 被引次数: 0
出版历程
- 收稿日期: 2022-08-09
- 网络出版日期: 2023-08-28

Practice of family physician contracted service under the whole process health management model in tertiary a-level hospital

MU Xingyu¹,
ZHANG Lin¹,
AN Kang¹,
SHI Yi¹,
LI Caizheng¹,
SHE Yi^{1, 2},
LI Shuangqing^{1, 2},
SU Qiaoli^{1
, ,}

1.
General Practice Medical Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China

摘要

摘要: 目的家庭医生签约服务已在我国各区域社区卫生服务中心进行了有益有效的实践，三甲医院的家庭医生签约服务实践形式多以社区卫生服务中心为主体，与社区单位进行联合，向基层医务人员提供技术指导和知识培训，并为双向转诊提供支撑。三甲医院独立进行健康管理的家庭医生签约服务模式尚有待探索。方法分析四川大学华西医院全科医学科近3年来开展的基于全程全周期健康管理的家庭医生签约服务模式实践，总结其运营机制，勾勒三甲医院家庭医生签约的服务模式，并分析三甲医院推行家庭医生签约服务可能存在的问题。结果四川大学华西医院全科医学科在家庭医生签约服务的过程中制定了签约医疗组管理制度和各岗位工作流程，完善签约人群的健康管理流程。全科医生团队通过在不同时间节点的介入，对家庭签约人群提供力所能及的、全方位的医疗照护及全程的健康管理，并与社区卫生服务中心组成上下联动机制，借此推动分级诊疗的落实。以全科医生团队为纽带，建立了三甲医院全程健康管理的家庭医生签约服务模式，形成全程健康管理服务平台。但如何向签约个体更好地提供三甲医院的优质诊疗技术、实行与社区的联动，以及对接“健康中国2030”尚需要进一步思索。结论三甲医院也可开展基于全程健康管理的家庭医生签约服务模式，为医疗资源的合理优化利用、分级诊疗的推进、医疗服务质量的提高提供有益的探索。
- 家庭医生签约服务 /
- 三甲医院 /
- 全科医生
Abstract: Objective The family physician contracted service has carried out beneficial practices in China's community health service centers. Most of the tertiary A-level hospitals take community health service centers as the main body, and cooperate with community units to provide technical guidance and knowledge training for medical staff, and provide support for two-way referrals. The family physician contracted service model independently carried out in tertiary A-level hospitals needs to be explored. Methods We analyzed the family physician contract service based on the whole process health management conducted by the General Medicine Department of West China Hospital of Sichuan University in the past three years, summarized its operation mechanism, outlined the service model, and analyzed the possible problems in the implementation in the tertiary A-level hospitals. Results We have established the management organization structure, the management system of the contracted medical team, formulated the work process of each job posting, and improved the health management process of the contracted personnel. The family doctor team provides all-round medical care and whole process health management for family contract patients at different time nodes, and forms an up-down linkage mechanism with the community center to promote hierarchical diagnosis and treatment. With the family doctor team as the link, the family doctor contract service mode of whole process health management in tertiary A-level hospital has been established, forming a whole process health management service platform. How to better provide the contracted individuals with high-quality diagnosis and treatment technology of tertiary A-level hospitals, and how to implement the community link and connect with Healthy China 2030 needs further consideration. Conclusion The tertiary A-level hospital can also carry out the contracted service mode of family doctor based on the whole process health management, so as to provide beneficial exploration for the rational and optimal utilization of medical resources, promote hierarchical diagnosis and treatment, and improve the quality of medical service.
- Family physician contracted service /
- Tertiary A-level hospital /
- General practitioners

HTML全文

参考文献(15)

[1]	景日泽, 冯黄于飞, 方海. 家庭医生签约服务制度的国际经验对中国的启示[J]. 中国农村卫生事业管理, 2020, 40(6): 387-392. doi: 10.3969/j.issn.1005-5916.2020.06.003 JING R Z, FENG H Y F, FANG H, et al. Implications of international experience of the contracted family doctor services for China[J]. Chinese Rural Health Service Administration, 2020, 40(6): 387-392. doi: 10.3969/j.issn.1005-5916.2020.06.003
[2]	裴晨阳, 肖瑶, 周梅芳. 美国健康维护组织的运作模式对我国老年人健康管理的启示[J]. 医学与社会, 2018, 31(11): 15-16, 20. https://www.cnki.com.cn/Article/CJFDTOTAL-YXSH201811005.htm PEI C Y, XIAO Y, ZHOU M F. Enlightenment of operation pattern of health maintenance organization in America to elderly health management in China[J]. Medicine and Society, 2018, 31(11): 15-16, 20. https://www.cnki.com.cn/Article/CJFDTOTAL-YXSH201811005.htm
[3]	贾梦, 王芳, 田淼淼, 等. 家庭医生签约制度国际特征及对我国的策略性启示[J]. 中国初级卫生保健, 2021, 35(5): 16-18. doi: 10.3969/j.issn.1001-568X.2021.05.0005 JIA M, WANG F, TIAN M M, et al. Insights of family physicians service models on the institutional strategy developing in China[J]. Chinese Primary Health Care, 2021, 35(5): 16-18. doi: 10.3969/j.issn.1001-568X.2021.05.0005
[4]	刘金玲, 沈勤, 陈国伶, 等. 杭州市居家老年人家庭型医养护一体化服务需求及影响因素研究[J]. 中国护理管理, 2018, 18(11): 1485-1491. doi: 10.3969/j.issn.1672-1756.2018.11.011 LIU J L, SHEN Q, CHEN G L, et al. The service requirements and related factors of the Integration of Medical Care, Elderly care and Nursing Care Model in community elderly in Hangzhou[J]. Chinese Nursing Management, 2018, 18(11): 1485-1491. doi: 10.3969/j.issn.1672-1756.2018.11.011
[5]	唐国宝, 姜杰. 厦门市"三师共管"家庭医生签约模式的实践与效果探讨[J]. 中华全科医师杂志, 2018, 17(7): 510-513. doi: 10.3760/cma.j.issn.1671-7368.2018.07.005 TANG G B, JIANG J. Implementation and effective of "Three-in-One" family doctor contract service model in Xiamen[J]. Chinese Journal of General Practice, 2018, 17(7): 510-513. doi: 10.3760/cma.j.issn.1671-7368.2018.07.005
[6]	陈斌, 李荣, 吴慧超. 上海市农村地区家庭医生"1+1+1"签约模式研究[J]. 现代医院管理, 2018, 16(4): 17-20. doi: 10.3969/j.issn.1672-4232.2018.04.006 CHEN B, LI R, WU H C. Research on "1+1+1"Mode of Family Doctor Service in Rural Areas of Shanghai[J]. Modern Hospital Management, 2018, 16(4): 17-20. doi: 10.3969/j.issn.1672-4232.2018.04.006
[7]	雷诗寒, 陈迎春, 苏岱, 等. 区域按人头总额预付对安徽省两县常见慢性病住院患者就医流向的影响[J]. 医学与社会, 2020, 33(12): 104-108, 118. https://www.cnki.com.cn/Article/CJFDTOTAL-YXSH202012021.htm LEI S H, CHEN Y C, SU D. Effect of regional global budget based on per capita on the flow direction of inpatients with common chronic diseases in two counties in Anhui province[J]. Medicine and Society, 2020, 33(12): 104-108, 118. https://www.cnki.com.cn/Article/CJFDTOTAL-YXSH202012021.htm
[8]	刘锐, 杨旦红, 吴欢云, 等. 通向健康中国的家庭医生签约服务模式比较研究[J]. 中国全科医学, 2020, 23(25): 3139-3145. doi: 10.12114/j.issn.1007-9572.2020.00.263 LIU R, YANG D H, WU H Y, et al. Contracted family doctor service models leading to healthy China: a comparative study[J]. Chinese General Practice, 2020, 23(25): 3139-3145. doi: 10.12114/j.issn.1007-9572.2020.00.263
[9]	徐昕, 黄倩, 寿涓, 等. 家庭医生心理疏导对社区"1+1+1"签约2型糖尿病患者心理状况的影响[J]. 中华全科医学, 2018, 16(12): 2056-2058, 2084. doi: 10.16766/j.cnki.issn.1674-4152.000509 XU X, HUANG Q, SHOU J, et al. The influence of family doctor's psychological counseling on the psychological status of type 2 diabetes mellitus with 1+1+1 contracted service in the community[J]. Chinese Journal of General Practice, 2018, 16(12): 2056-2058, 2084. doi: 10.16766/j.cnki.issn.1674-4152.000509
[10]	张薇琪, 袁蕙芸. 上海市居民对家庭医生制度满意度的影响因素研究[J]. 中华全科医学, 2022, 20(2): 270-273. doi: 10.16766/j.cnki.issn.1674-4152.002330 ZHANG W Q, YUAN H Y. Influencing factors of resident satisfaction with the family doctor system in Shanghai[J]. Chinese Journal of General Practice, 2022, 20(2): 270-273. doi: 10.16766/j.cnki.issn.1674-4152.002330
[11]	张肇祺. 中国老龄化社会阶段家庭医生制度的实施现状[J]. 河北医药, 2018, 40(24): 3814-3817. doi: 10.3969/j.issn.1002-7386.2018.24.035 ZHANG Z Q. The implementation current situation of family doctor system in China's aging society[J]. Hebei Medical Journal, 2018, 40(24): 3814-3817. doi: 10.3969/j.issn.1002-7386.2018.24.035
[12]	季晖. "1+1+1"医疗机构组合签约影响因素研究[J]. 中华全科医学, 2021, 19(3): 436-440. doi: 10.16766/j.cnki.issn.1674-4152.001895 JI H. Study on the influencing factors of "1+1+1"type of contracted family doctor services[J]. Chinese Journal of General Practice, 2021, 19(3): 436-440. doi: 10.16766/j.cnki.issn.1674-4152.001895
[13]	王志翊, 王仲, 翁杰, 等. 医联体全科团队对居民家庭医生签约意愿的影响研究[J]. 中国全科医学, 2018, 21(27): 3389-3392. doi: 10.3969/j.issn.1007-9572.2018.00.184 WANG Z Y, WANG Z, WENG J, et al. The influence of general practice alliance on the residents' willingness to sign a family physician[J]. Chinese General Practice, 2018, 21(27): 3389-3392. doi: 10.3969/j.issn.1007-9572.2018.00.184
[14]	董海影, 兴桂华, 孙玉荣, 等. 依托"互联网+大数据"构建病理医联体平台的思考[J]. 中华医学教育探索杂志, 2020, 19(8): 987-989. doi: 10.3760/cma.j.cn116021-20191214-00227 DONG H Y, XING G H, SUN Y R, et al. Thoughts on the construction of pathology medical alliance platform based on Internet plus and big data[J]. Chinese Journal of Medical Education Research, 2020, 19(8): 987-989. doi: 10.3760/cma.j.cn116021-20191214-00227
[15]	张玉彩, 谢春, 香利强, 等. 紧密型医联体模式下全科医学科建设探索[J]. 中华全科医学, 2019, 17(4): 661-665. doi: 10.16766/j.cnki.issn.1674-4152.000761 ZHANG Y C, XIE C, XIANG L Q, et al. Exploration of the construction of general medicine department under the close medical association[J]. Chinese Journal of General Practice, 2019, 17(4): 661-665. doi: 10.16766/j.cnki.issn.1674-4152.000761