以门诊为中心的社区糖尿病综合管理模式构建

背景　以社区为依托开展慢性病管理，是目前最为有效的手段。社区慢性病管理主要以门诊为主，但全科医生门诊仍以开药为主，缺少健康咨询、患者随访等服务，服务质量也参差不齐。对于糖尿病等常见的慢性病病种，社区缺少相关人群管理的绩效考核体系和医生操作行为规范。目的　构建以门诊为中心的社区糖尿病综合管理模式，为社区糖尿病管理融入社区医务人员现有工作奠定基础。方法　2017年7-9月通过文献回顾、专家咨询和实践总结，对社区糖尿病管理服务内容进行盘点；通过头脑风暴，对以门诊为中心的社区糖尿病管理流程进行梳理。结果　以门诊为中心的社区糖尿病综合管理模式的服务内容有健康档案管理、普通门诊诊查、转诊、药物治疗、用药指导、饮食指导、运动指导、自我血糖监测指导、随访、健康教育、体格检查和实验室检查服务。服务流程以门诊为核心，在居民就诊挂号后增加糖尿病风险识别、健康档案建立流程，其他流程与现有门诊流程一致。结论　以门诊为中心的社区糖尿病综合管理模式的有序运行，需要以健康档案的建立、共享为前提，以任务的合理分工为基础，且注意与其现有的工作少有冲突。

Construction of the Outpatient-centered Model to Comprehensively Manage Diabetes in Community

Background　Relying on the community is the most effective means of chronic disease management.Community chronic disease management is mainly based on outpatient service，but the outpatient service of general practitioners is still based on prescribing drugs and lacks health consultation and patient follow-up with uneven quality of service.For common chronic diseases such as diabetes，the community also lacks the performance appraisal system for the relevant population management and the operational behavior norms for doctors.Objective　To construct an outpatient-centered diabetes management model，so that to lay the foundation for the community diabetes management to integrate into the existing work of medical staff in community.Methods　Through literature review，expert consultation and practice summary，this study conducted an inventory of community diabetes management services from July to September 2017.Through brainstorming，the outpatient-centered community diabetes management process was sorted out.Results　In the outpatient-centered diabetes management model in community，a series of services were provided with residents，such as health records，general outpatient consultation，referral，drug treatment，medication guidance，diet guidance，exercise instruction，self-monitoring of blood glucose instruction，follow-up，health education，related physical examinations and laboratory inspection services.The service process in this model was centered on outpatient clinic，and in addition to increasing the identification of diabetes risk and health records for residents，other processes was consistent with the existing outpatient process.Conclusion　The orderly operation of the outpatient-centered diabetes management model needs to be based on the establishment and sharing of health records，and also needs the rational division of tasks，and there are few conflicts with their existing work in this model.