医院和社区卫生机构间连续性医疗服务模型研究

摘要

通过对国内外连续性医疗服务的研究及对其内涵特征进行分析,提出了从4个维度构建适宜于我国卫生系统发展的城市医院和社区卫生机构之间提供连续性医疗服务的模型:一是信息连续服务.患者诊疗信息在不同服务提供者之间完整、及时地传递和衔接.二是机构连续.即由专业计划和安排为患者选择适宜的机构进行诊疗服务的传递和衔接.三是专业连续.卫生机构回归各自功能定位,以慢病管理团队、会诊等形式开展多专业协同服务.四是人际连续.能够建立患者和社区卫生机构以及不同卫生机构服务提供者之间稳定信任的关系.%In this article, the investigations and intemal characteristics of successive medical service at home and abroad are analyzed.The model of continuity medical care between urban hospitals and Community health service institutes, is constructed from four dimensions.The first one is information continuity, which also means patients' basic situation, diagnosing and treatment information is delivered integrally and timely within the different service providers.The second is agencies continuity, which also means when patients need to be treated within the different health agencies, referrals is planned professionaily.Another one is interdisciplinary continuity.Services depending on the cooperation among different professions are provided in the form of teamwork based on the management of chronic diseases and consultation.Finally,it is relationship continuity.Stable connections and trust are established within the patients and service providers.