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目的
探讨三级医院“家庭护士”服务模式对慢性病延续医疗服务的作用与影响。 方法 三级医院成立家庭护士服务部及顾问医生团队，与出院慢性病患者签定延续医疗服务约定，并借助信息化平台，建立以签约对象为中心，以家庭、社区、医院为一体的无缝医疗服务链。统计2016年1—9月“家庭护士”服务模式应用的相关指标。 结果 “家庭护士”服务模式应用后，26家社区卫生服务中心与三级医院签约并成立医疗联合体，262例慢性病出院患者与家庭护士服务部签定延续医疗服务约定；慢性病签约患者及社区卫生服务机构人员的满意度分别为99.8%和90.0%等。结论 “家庭护士”服务模式构建与应用，引导了慢性病患者科学合理就医秩序，增强了三级医院与社区卫生机构的上下联动，提高了慢性病患者满意度。 |
| 关键词: 慢性病 延续医疗服务 家庭护士 服务模式 三级医院 签约对象 |
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| Construction and Application of Home Nurses Service Model in Tertiary Hospitals Based on Continuing Medical Service for Chronic Diseases |
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| Abstract: |
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Objective To explore the effect of the home nurses service model in tertiary hospitals on continuing medical service for chronic diseases. Methods Tertiary hospitals set up home nurses service department and consultant doctors team,signed a contract in continuing medical service with the discharged patients of chronic diseases, and with the help of information platform took the family, community and hospital as a whole and established a seamless service chain for the signatory client ,so as to provide continuous and hierarchical health management services. The relevant indexes of home nurses service model were analyzed from January to September, 2016. Results After the application of home nurses service model, 26 community health service centers and the tertiary hospitals established the medical cooperation; 262 discharge patients with chronic disease signed up with home nurses service department for continuation medical services. The degree of satisfaction of signatory clients and community staff were 99.8% and 90.0%, respectively. Conclusion The construction and application of the home nurses service model in tertiary hospitals has guided the clients to choose hospital scientifically and reasonably. It enhanced the linkage of tertiary hospitals and community health centers. And it improved the satisfaction of discharged patients with chronic diseases. |
| Key words: chronic disease,continuing medical service,home nurses service model,tertiary hospital,signatory clients |
