关键词: 分级医疗, 家庭医生签约服务, 心力衰竭, 全科医学

Abstract: Based on the "1+1+1" hierarchical contractual service delivery mode implemented in Shanghai，Weifang Community Health Service Center（WCHSC） and Renji Hospital，Shanghai Jiaotong University School of Medicine（RHSJUSM） co-developed a general-specialty hierarchical management mode for chronic heart failure（CHF）．This mode of care is co-delivered by both WCHSC（offering primary care） and RHSJUSM（offering specialty care） in Renji-Weifang CHF Studio in WCHSC，using the co-developed CHF hierarchical diagnostic and treatment criteria（based on NYHA functional class，body weight changes，and BNP or NT-proBNP），and referral procedure，under the conditions of sharing drugs，as well as laboratory test results for CHF.We detailedly introduced both the theory and implementation of general-specialty hierarchical management mode for CHF，and put forward that，using this mode is contributive to the appropriate allocation of high-quality medical resources to primary healthcare institutions，to the improvement of GPs' diagnostic and therapeutic ability，and to the identification of the severity of disease in a more simple and effective way.Moreover，during the management，with the help of the full-time assistant in monitoring weight and consecutive self-management，the self-management compliance of patients can be improved.This mode is helpful to form a hierarchical diagnosis and treatment model characterized by separate treatment of acute and chronic diseases，and cooperation between higher- and lower-level healthcare institutions.

Key words: Hierarchical medical treatment, Contracted family doctor services , Heart failure, General practice