Focus on Guilin's medical reform: "Gongcheng Model" of the "group system" health management

■ Focus on the report of Guilin Medical Reform Series (2)

(Original title) The level of health literacy of residents has steadily improved the management rate of chronic disease specifications and the significant increase in standards.

"Gongcheng Mode" of "Group System" health management

The level of health literacy of residents increased from 14.40%in 2017 to 18.98%in 2020, and then 20.35%in 2021; the management rate of hypertension norm was 92.78%, the control rate reached 81.09%; , Objective complications ... This is a chronic disease management answer sheet surrendered by Gongcheng Yao Autonomous County.

Behind this group of numbers is the reduction in the incidence of chronic diseases of Gongcheng, and patients spend less money, and the medical burden is reduced. How is this achievement achieve? Investigating its roots, Gongcheng actively builds a "group system" health management model is an important reason. Recently, the reporter came to Gongcheng's earliest pilot village to implement this model -Qiaotou Village to explore the secrets of "group system" health management.

Establish a health management team to linked the "Health Grid"

The aging of the population is an important trend of social development, and it is also the basic national conditions in my country in the future. The relevant person in charge of the National Health and Health Commission stated at a press conference held at the end of last year that with the gradual increase of the life expectancy of the per capita, my country is entering the era of longevity, but many elderly people have the problem of unhealthy longevity. my country has chronic diseases of 190 million elderly people.

In fact, not only the elderly, in recent years, chronic diseases such as hypertension and diabetes have also begun to "entangle" young people, and many chronic diseases have shown a younger trend. For people with chronic diseases, improving a sense of health, taking medicine and regular examination on time can effectively control the development of the disease. For healthy people, it is also very important to establish a correct concept of health and prevent it.

In order to thoroughly implement the development concept of "centered on people's health", promote the county's construction of a high -quality and efficient medical and health service system, realize the implementation of local pilot project work, and realize the health, mental health, moral health, and social relationship health of the people The goal of the "Four Health" goals has moved forward to the goal of "Beautiful Gongcheng, Healthy Gongcheng, Cultural Gongcheng, Fu Fu Gongcheng, Happy Gongcheng". County and rural integration management, strive to build a integrated health service system for medical defense integration. By exploring the use of the new model of "group system" to provide high -quality and efficient health management services for residents, it will achieve comprehensive health management of residents.

Peng Shengxing, a member of the Party Group of the Health and Health Bureau of Gongcheng Yao Autonomous County and the director of the aging service center, introduced that the pest of chronic diseases is high, but many residents have insufficient health awareness. Even patients with chronic diseases are not positive. Therefore, it is imminent to enhance basic public health services and chronic disease management services.

Although we realize to improve the health awareness of residents, how to improve is still a big problem. If the county or townships are managed, the number of residents is relatively difficult due to the large number of residents, but if each township is divided into a small area, then it is relatively simple in management, and it is more likely to obtain obtaining it. Effective.

Peng Shengxing said that many rural villages in the county have implemented a "group system" management model, which is mainly responsible for morality, safety and sanitation. About three years ago, in order to facilitate the health management of residents, these groups had the functions of health management.

It is understood that in accordance with the principles of living, easy concentration, and facilitating management, the health group forms a group every 10-15 farmers, and every 2-3 groups form a large group. Party members, villagers' backbone, etc. are selected as the team leader and team leader, and they will assist the village committees of the Gongcheng County Medical Community Service Center (County Medical Group), village clinics, and township health centers and health management companies to carry out villagers. Health management work forms a five -level linkage health management network of "counties, townships, villages, villages, tuning, and groups.

As of now, 127 administrative villages in Gongcheng County have selected 2061 team leaders and 4,396 group leaders, which laid the "red grid", "health grid" and "happiness grid" that served the masses. solid foundation.

Layered management for residents health care escorting residents health care

Recently, the reporter came to Qiaotou Village, Ping'an Town, Gongcheng to visit the "group system" health management "Gongcheng model" on the spot.

In 2019, after trying the "group system" health management model, Qiaotou Village divided the whole village into 5 large groups and 10 health groups to carry out healthy management of more than 170 residents. Since then, the villagers have become a health team leader in the village.

He told reporters that the team leader was like a "propagandist". He was usually responsible for assisting in notifying patients with chronic diseases to test blood sugar and blood pressure in the village clinic, urging them to conduct lectures on health knowledge, and led the villagers to establish a good lifestyle. At the same time, the team leader is also a "liaison" between villagers and village doctors. It must not only assist village doctors and health managers to complete the update of residents' health files, but also guide them to explain and publicize health knowledge.

"Usually every two or three months of the village will conduct a health education class. After receiving the news of the start, I will notify the dozen villagers I managed and notify them to go to class." The village clinics will conduct chronic disease examinations such as hypertension and diabetes every year. During the medical examination day, he also reminds and urge the villagers to participate in the medical examination on time. "I usually go to the villagers 'houses to promote health knowledge in the villagers' homes to help them improve their awareness of health." The village clinics also set up files from the residents of the residents, from the three aspects of the residents' health stall questionnaire, chronic diseases questionnaire table, and physical examination reporting reports of the medical examination institution. The health status of residents jurisdiction. Subsequently, the corresponding health management plan is formulated according to the health status of different groups: a lecture on a chronic disease prevention knowledge on the health group; the sub -healthy people formulate preventive intervention measures for different body abnormal indicators; The management platform formulates personalized health management solutions from five aspects: diet, exercise, drugs, monitoring, and psychological adjustment.

According to statistics, in 2021, the toilet of Qiaotou Village, Ping'an Town completed 958 follow -up monitoring of the household survey of patients with hypertension, and 148 follow -up monitoring of diabetes households; Monitoring 525 times, 92 follow -up monitoring of diabetes household surveys; 372 follow -up monitoring of high blood pressure survey surveys of Hushan Village, Lianhua Town, and 36 follow -up monitoring of diabetes household surveys.

Li Ningfeng, a doctor in the second toilet village of Qiaotou Village, said that the toilet also equipped patients with blood glucose and "Healthy Life Record Forms" for patients with relatively large blood sugar and blood pressure fluctuations. Records of diet, exercise and other living conditions. "We go to the villagers 'houses every week to recover the records to learn about their situation this week. If they find that the villagers' physical indicators are abnormal and cannot be processed, they will be referred to the higher -level health centers or county -level hospitals in time to allow patients to receive treatment as soon as possible. "

Residents' health awareness improvement of medical defense integration and effectiveness

The villager Tang Dynasty of Qiaotou Village was a patient with a hypertension. He told reporters that he found that he had suffered from hypertension when he was in a physical examination in the village clinic. "I did n’t have a regular medical examination before. After the“ group system system 'health management was implemented, the village doctor regularly checked us, and I knew that I had high blood pressure. "He told reporters that thanks to this management model, now he is very very very good Pay attention to your own health, not only will you regularly go to the village clinics for physical examination, but also buy a blood pressure meter and measure blood pressure at home every day.

At his home, the reporter saw a smart pill box assigned by a village clinic. The medicine box has a voice reminder function, which reminds him of taking medicine regularly every morning. "Now the villagers in the group are significantly enhanced. In the past, even if some people knew that they had hypertension and diabetes, they thought it didn't matter, but now everyone pays more attention to smoke and alcohol in diet."

The villager Chen Shuangqiao also said that the team leader was very serious and responsible. Every time there were health lectures and medical examinations, they would notify the villagers one by one. "When encountering an elderly person with a strong sense of health, the team leader will also contact the young people in their house and let them take the elderly to the medical examination regularly." He told reporters that through the "group system" health management, he learned a lot of health knowledge. Lifetime is also more regular and healthier than before.

He Zhiming, Deputy Dean of the People's Hospital of Gongcheng Yao Autonomous County, told reporters that in order to better carry out health education, the hospital will formulate a corresponding training plan every month to conduct first aid knowledge of medical staff, village doctors, and group leaders of township health centers. , Seasonal common diseases, chronic diseases related knowledge and other content training. In addition, the township health centers also conducted preaching and training of relevant personnel of the association, allowing them to impart cutting -edge health care knowledge to patients and their families.

In addition, according to Zhou Peixing, dean of the Health Center of Ping'an Town, 9 towns and villages in Gongcheng County also formed a family doctor signing service team. Each team consists of clinicians, public health doctors, nurses and village doctors of the township health centers. "The family doctor team is also an important carrier of the health management work of the" group system ". They work in the form of a piece of wrap. Each small team is responsible for the screening and follow -up of the disease screening and follow -up of 2,000 villagers."

In the past three years, through some initiatives, Gongcheng's "group system" health management model has achieved certain results. According to statistics, since the establishment of a "group system" health management model, the number of archives in the second toilet of Qiaotou Village has reached 3,579, and a total of 228 patients with hypertension have been managed. The management rate of hypertension has reached 93%. , Standardized management rate reached 80%; Bayan Village Centers completed 2491 health files, managed 147 patients with hypertension, standardized management rate of 85%, managed 24 diabetic patients, regulated management reached 70%; The number of people is 1470, managed 106 patients with hypertension, a standardized management rate of 69%, and managing 7 diabetic patients and a standardized management rate of 70%.

- END -