Health management of patients with medical defense integrated chronic diseases accelerated in Henan

(Reporter Feng Jincan) On August 3, the reporter learned from the health management pilot work conference of the health management of patients with medical and defense integrated chronic diseases in Henan Province that Henan took a contract with family doctors as a starting point to take the national basic public health service Relying on the project, taking the health management of patients with hypertension and diabetes as the breakthrough, carry out the health management pilot work of patients with medical defense integrated chronic diseases, improve the health and sense of obtaining the health of patients with chronic diseases, reduce the incidence and hospitalization rate of complications, reduce medical expenses burden.

The Provincial Health Commission requires that the district medical communities in the pilot areas shall set up a public health and health management center to be responsible for public health services, family doctors signing services, and health management in the medical communist. The county -level disease prevention and control center can send part -time deputy dean and technical backbone to the medical community to guide the health management of patients with public health and chronic diseases. Township Health Center (Community Health Service Center) shall set up a family doctor contract service and public health department (adding the brand brand of the Slow Disease Health Management Office). Services, public health and health management of patients with chronic diseases. Rural doctors participate in the family doctor service team and are responsible for providing health management services, public health services, and health management services within their duties. Rural doctors with stipulated conditions and participating in rural integration management can take the lead in setting up a family doctor service team.

The pilot area of ​​the township health center (community health service center) must set up the general medical department of the general science and medicine, and establish a number of family doctors to sign the service team with the general physicians, and set up a clinic for each team, equipped with a family doctor assistant (nurse or public health personnel personnel personnel (nurse or public health personnel personnel Wait), provide basic medical care, basic public health and full health management services for patients with hypertension and diabetes. The township health center (community health service center) has set up a comprehensive service station for outpatient clinics. The nurse (family doctor assistant) provides patients with appointment, section, consultation and body temperature, blood pressure, blood sugar measurement, etc. Carry out health education, behavioral intervention, follow -up follow -up, referral coordination and other post -consultation services. Encourage the application of new technologies for reservation, remote medical and artificial intelligence. Encourage township health centers (community health service centers) to set up a comprehensive traditional Chinese medicine service area (traditional Chinese medicine museum), maternal and child health comprehensive service area, and special specialty service area. While providing general medical services for township health centers (community health service centers), they are encouraged, while providing general medical services, according to their own actual and talent technical advantages, set up specialized specialties and joint clinics for specialist specialties, and carry out appropriate specialty specialty services. The county medical community led the hospital to set up a family doctor to sign a contract service expert guidance team to go to the township health center (community health service center) to attend the consultation and teach, participate in the signing service of family doctors, and provide technical guidance and work coordination.

The Provincial Health and Health Commission requires that the pilot area takes the contract service team as the basic assessment unit, and the evaluation content includes basic medical services, basic public health services, and health management services for patients with chronic diseases. It also reflects the role of family doctors' "Health Stopers" and "Medical Cost Stopers" for signed residents. Based on the results of performance evaluation, we have worked hard, excellent performance, rewards and punishment, and linked to salary distribution and evaluation of excellence, job title (position) promotion.

In response to the next step, the Provincial Health and Health Commission requires all pilot areas to further improve awareness, enhance the sense of urgency and responsibility, highlight the focus of work, seize key links, and make a good summary of experience and publicity. In particular, we must find a job grasp and support, and strive to do a good job of organizing management integration, service team integration, service process integration, information system integration, and performance assessment. The relationship between the relationship, the relationship between basic public health services and basic medical services, the relationship between the general medical and characteristic specialties, the relationship between the people and the disease, and truly shifted from cure to health.

The meeting invited Wang Xianjun, director of the Yuyu Road Community Health Service Center of Shapingba District, Chongqing, to share the theme of "Reform Practice of the Primary Medical and Health Institution '5H' Medical Defense Integration Service Model Reform". The director of 10 pilot counties (cities), including Gongyi City, Lancao County, Qixian County, Dancheng County, etc., reported on the progress of the pilot work, existing problems, and the next plan.

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