关键词: 全科医生团队, 慢性病, 服务流程, 社区卫生服务

Abstract: Background　The prevention and control of chronic disease in China is in a severe situation,and chronic disease service at this stage is not optimistic.Objective　To understand service process of chronic disease,find out the existing problems,and provide basis for improving quality of community health services and relevant policies and measures set out by our government authorities.Methods　29 community health service centers in two urban areas of Guiyang downtown were investigated in October 2015,two centers did not cooperate with the investigation,and actually 27 were in the survey.Under qualitative research method,principals of 27 community health service centers and leaders of general practitioner team were interviewed deeply with self-made interview outline.Interview contents included service process and major service contents provided by general practitioner team for community chronic disease patients （including discovery of patients with chronic diseases,screening,follow-up,physical examination,management,treatment,usage of health records,etc.）.Results　Each community health service center in main urban area of Guiyang City had an average of 1 to 2 general practitioner teams,each team was responsible for basic public health services of about 1 500 residents who had signed health service agreements,200 to 300 of them were patients with chronic diseases.General practitioner team members undertook the work of residents’ outpatient service,chronic disease screening,finding and management.Chronic disease management team was mainly responsible for chronic disease management,and it was the branch of general practitioner team.44.4% （12/27） of chronic disease management teams were led by doctors,44.4% （12/27） led by nurses,11.2% （3/27） led by non-medical professionals.Non-clinical professionals such as community nurses were mainly responsible for follow-up of chronic diseases,putting forward lifestyle guidance,and general practitioners for proposing medication guidance.25.9% （7/27） of community health service centers set up specialized community chronic disease clinics,59.3% （16/27） did not and shared with the outpatient clinics of general practice,11.1% （3/27） depended on outpatient medical care of superior hospitals,and another 3.7% （1/27） did not provide clinical outpatient services.Health records in the service process of chronic disease were mainly used for recording follow-up and physical examination information.There were 4 kinds of cooperative ways of general practitioner team in the management process of patients with chronic disease:service principals of chronic outpatient,chronic disease management department,relying on medical services of superior hospitals and lacking of medical care.Conclusion　The chronic disease service processes of general practitioner team basically comply with requirements of national regulations,but phenomena such as the separation between basic medical care and basic public health services,imperfect teamwork mechanism,insufficient effectiveness of health guidance,and lacking of effective use of health records are still existed.

Key words: General practitioner team, Chronic disease, Service process, Community health services