全人群家庭医生服务的体系初探.docVIP

全人群家庭医生服务的体系初探 　　摘 要 家庭医生制度在国际上是一项历史悠久的基层医疗制度。目前，国内的家庭医生制度尚处在起步阶段。康健街道社区卫生服务中心作为徐汇区首批试点单位，正在推行全人群家庭医生服务模式。然而，根据中心的人力资源状况，无法单纯依靠全科团队来开展全人群家庭医生服务。中心通过建立以全体全科医生为服务主体，公共卫生人员、社区护士、社区医疗资源为支撑团队的服务体系，履行签约、建档、基本医疗、基本公共卫生、转诊、健康咨询、健康评估等多项服务承诺。在初步探索过程中，实现了近40%的家庭医生服务覆盖率，在合理就医、按需转诊、满足居民家庭病床需求和健康咨询需求、扩大慢性病管理覆盖面等方面取得了初步成效；在利用现代媒介实现家庭医生与居民的沟通、服务、慢性病双向管理方面进行了大胆尝试；在提升家庭医生健康管理内涵、对签约居民实施健康评估方面迈出了第一步，并在较短的时间内解决了服务与需求两者之间的矛盾。 　　关键词 全人群 家庭医生 服务体系 　　中图分类号：R192 文献标识码：C 文章编号：1006-1533（2012）06-0022-03 　　Study on the family doctor service system for the whole crowd 　　LI Zhen-yu, YI Chun-tao, ZHU Li-zhen, 　　（Kangjian Community Health Service Center, Xuhui District, Shanghai） 　　ABSTRACT The family doctor system in the world has a long history of primary health care system. At present, China is still at the initial stage of the family doctor system. Kangjian community health service center as the first batch of pilot units of the family doctor service system in Xuhui District, is carrying out the family doctor service system to the whole population. However, according to the center’s human resources, it can not support the teams to carry out the family doctor service system lonely. The center, relying on the general practitioners as the main body, and getting support from the public health personnel, community nurses, other community health resources performs the signing contracts, establishing files, providing basic medical care, basic public health, referral, health advice, health assessment and a number of service commitments. In the experiment process, 40% of the population has been covered by the family doctor service. The reasonable service, on-demand referral, meeting the residents of family sickbed demand and health consultation requirement, expanding the coverage of chronic disease management has obtained the initial effect. The bold attempt has been undertaken in the use of modern media family doctors and residents’ communication, service, chronic disease bidirectional managemen