摘要
本研究通过借助智慧家庭医生优化协同模式整合社区资源的同时,由家庭医生式服务团队通过信息化手段利用社区卫生管理平台数据,为辖区脑卒中签约患者推送个性化、一对一健康管理服务信息。建立双向转诊通道,为辖区脑卒中签约患者搭建"医院-社区-居家"的延续照护平台,解决其出院后居家延续照护中存在和潜在的问题,为医养结合延续照护的实践提供方案和思路。经过前期准备和实践,双向转诊通道得到了良好的应用,实现了辖区脑卒中签约患者的"医院-社区"转入转出,从而验证该路径的确行之有效,将"上下联动、延续照护、多方协作"这一概念付诸实践。
The aim-is to introduce and offer personalizec[and one-to-one health management information to signatory stroke patients of Fangzhuang Community Health Service Center by their family doctor service team, based on the Intelligent Family doctors Optimized Coordination model to integrate community resources as well as data from the Community Health Management Platform. The two-way referral channel has been established to build a ＂hospital-community- home＂ continuation of care platform, in order to address the present and potential issues for those discharged signatory stroke patients, and provide schemes and ideas to practice of the combination of medical treatment and endowment. After preparation and practice in advance, the two-way referral channel has been applied well, and the ＂hospital-community＂ dual referral system has been achieved, so as to verify the path is effective. Meanwhile, the concept of ＂up and down linked, continual nursing and multiparty cooperation＂ has been put into practice.
作者
王俊星
王丽
降依然
郭晓玲
何伟明
蔺惠芳
张坤
王颖
WANG Junxing WANG Li JIANG Yiran GUO Xiaoling HE Weiming LIN Huifang ZHANG Kun WANG Ying(Fangzhuang Community Health Service Center, Beijing, 100078, China)
出处
《中国护理管理》
CSCD
2017年第4期448-452,共5页
Chinese Nursing Management
基金
首都卫生发展科研专项项目(2014-2-7051
2016-3-7052)
北京市卫生系统高层次卫生技术人才培养计划(2014-3-105)
首都全科医学研究专项面上项目(16QK09)
卫生标准工作省综合试点项目--"互联网+社区健康管理"标准化试点研究
北京中医药传承双百工程(京中医科字[2015]180号)
作者简介
王俊星，专科，主管护师
通信作者：王丽，本科，主管护师，护理部主任，Email：908119156@qq．com
