家庭医生制度的健康管理实践与成效分析--以上海市长宁区为例

摘要

Family Doctor System is thought to be an eff ective way to control chronic diseases outbreak by providing continuous, personalized, and integrated services. In Changning, a mature family doctor system has been established after ten years practice, which has achieved ordered and eff ective health management service by several steps including highlighting family doctor as the main responsibility body of health management, constructing service platform, enriching health management service contents, innovating health management service model, and developing health management partnership. Evidence-based data shows that family doctor has made patients with chronic diseases “managed”, “moved” and “improved”. It could be concluded that Family Doctor System is a feasible, realistic and eff ective way to deal with the challenge of chronic disease prevalent in aging society.%家庭医生制度通过提供连续性、个性化、综合性服务，实现防治一体化管理，被认为是应对慢性疾病井喷的有效路径。上海市长宁区通过长达十年的基层卫生实践，形成了较为成熟的家庭责任医生制度，通过明确健康管理责任主体、搭建健康管理服务平台、丰富健康管理服务内涵、创新健康管理服务模式、构建健康管理伙伴关系，实现有序有效的健康管理服务。实证数据表明，签约家庭医生确实使慢病患者“管起来”“动起来”“好起来”，家庭医生制度是应对老龄社会慢病挑战可行、现实、有效的路径。