Hanyin County, Ankang City actively promotes the integration of medical defense integration

Since the beginning of this year, Hanyin County has actively explored the "433" service model of medical defense integration, accelerating the centered transformation centered on cure of diseases, promoting the integration and development of medical and public health services, and continuously reducing chronic diseases such as hypertension and diabetes in the masses The incidence rate.

The county adheres to the principles of prevention and control of prevention and control. The health services such as hypertension and diabetes (hereinafter referred to as "two diseases") are the breakthroughs. Relying on the construction of the county medical communities, the "four items" integration is accelerated. The first is to promote the integration of the system. Leveraged by the County Centers for Disease Control and Prevention, taking the medical community as the carrier, the county's medical control center, county -town village three -level medical institutions were integrated to form a third -level medical prevention integration system, and the "two diseases medical prevention monitoring centers" were established in the county disease control center. , Taking the three -level medical institutions of the county and town as a medical defense integration monitoring point, and the composite medical personnel with medical, defense, and management capabilities as the core, undertake monitoring screening, information reporting, health guidance, medical treatment and technical training. Sinking professionals conduct guidance and collaboration. Give full play to the role of the physician team, guide patients to participate in the formulation of treatment and management programs and carry out self -management. The second is to promote the integration of management. Package the medical insurance funds and basic public health management funds to the medical community for unified distribution, and link the assessment results to the basic public health chronic disease management funds. Give full play to the leverage of medical insurance funds, and gradually reverse the situation of "heavy control". The third is to promote information integration. Establish a three -level information connection feedback mechanism to screen, diagnose, treat, manage, manage, and follow -up information of the three -level medical institutions of counties and villages and villages and villages. Provide important information support for the full cycle service of "two diseases" patients. The fourth is to promote service integration. Improve the signing service model, implement grid management, establish a "1+1+1" working mechanism, consisting of a family doctor signing service team consisting of the three -level clinicians of the county, town, and village. Each team is equipped with at least 1 general doctor, 1 Famous rural doctors and a county -level hospital cardiovascular or endocrine specialist instructor divide the town and villages as grids to implement a grid responsibility system for the physician team. According to the signing content, the physician team provides patients with comprehensive, continuous, dynamic health management, disease diagnosis and treatment and other services for patients. Effectively combine health management with disease diagnosis and treatment services, give full play to the role of traditional Chinese medicine in the "two diseases" prevention, diagnosis and treatment, and health management, and formulate treatment plans for patients with primary hypertension and type 2 diabetes. Hierarchical diagnosis and treatment services, establish electronic health files, and standardize daily treatment, physical examination, and health management.

The county conscientiously implemented three prevention (prevention of hypertension and diabetes, preventing "two diseases" complications, and preventing complications from progress). The first is to do a good job of health education. Strengthen the construction of propaganda positions, and use the "two diseases" prevention and treatment knowledge as an important part of the health window of town and village medical institutions; use display screens, promotional pages, WeChat public accounts, knowledge lectures, etc. "The occurrence of the patient's healthy self -management. The second is to carry out a health checkup. Patients with "two diseases" are diagnosed with health examinations once a year, health assessment, screening complications, files with complications, follow -up management, follow -up management. The third is precise implementation of treatment. According to the patient's conditional changes and referral standards, the hierarchical diagnosis and treatment system is strictly implemented. After the family members who need to refer to the family members are agreed, the township hospital will be transferred to the county -level hospital to formulate personalized and standardized treatment plans in accordance with the guidelines and standardization of disease diagnosis and treatment. After the patient's condition was stable, he moved to the town health center to continue treatment, and evaluated his medical quality and medical effect to achieve orderly operation in order.

The county implements the three parties responsibilities, and the county disease control center is responsible for implementation and business guidance of the “two diseases” patients' medical prevention integration tasks. The assessment method is linked to the distribution of funds. The county -level hospital is responsible for sinking professional medical staff, regularly conduct professional knowledge training, guide the family doctor team to carry out "two diseases" health management, do a good job of disease screening, treatment of treatment, and refer to the inpatient patients in the rehabilitation period. Essence The county people's hospital played the technical support of chest pain centers and stroke centers, cooperated with the town health hospitals to carry out rehabilitation treatment of patients with "two diseases", and evaluated the quality of "two diseases" hierarchical diagnosis and treatment services. The town health centers are responsible for the preliminary clinical diagnosis of "two diseases", formulate personalized and standardized treatment plans, and establish "two diseases" electronic health files and information accounts. Organize and implement the annual health examination of patients, carry out specialized medical examinations and complications screening. Strengthen service supervision and comprehensively implement the grid management of the physician team. If a long -term prescription is issued according to the needs of patients, if the town health center does not have corresponding conditions, relying on remote consultation, Internet review, hospital consultation, etc. under the guidance of county -level hospitals. Through the implementation of medical and defense integration, we strive to create a new service model of "early prevention, early prevention, minor illnesses, diagnosis can be diagnosed, chronic disease management, referral help docking", and continuously improve the "two diseases" patients with grass -roots consultation rates and standards Management service rate effectively reduces the risk of complications.

(Liu Yong)

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