Challenge of Sustainable Development to General Practice in China：Management Strategies for Multiple Chronic Diseases in the Community

doi:10.12114/j.issn.1007-9572.2020.00.576

Abstract

Abstract: Against the backdrop of ever-increasing medical care needs and heavy burden of chronic diseases in the growing aging population，how to successfully manage multiple chronic diseases in the community has posed a challenge to the sound and sustainable development of primary care and general practice in China，which is still in an exploratory stage. We made a detailed discussion of the theory and practice（consisting of three key steps for general practice team fostering and environmental preparation and patient-centered healthcare and shared decision making） related to community-based management of multiple chronic diseases based on the review of relevant novel developments，to explore a better way for community-based management of multiple chronic diseases and to offer a reference for the sustainable development of general practice in China.

Key words: Multiple chronic diseases, Community health services, General practice

摘要： 随着全球人口老龄化的不断进展，面对逐渐增长的医疗需求和日益沉重的慢性病负担，实现对社区多重慢性病的管理将逐渐成为我国初级卫生保健及全科医疗环境探索阶段得以持续取得积极效果的挑战之一。本文总结国内外对多重慢性病管理的现况及研究进展，从“全科医疗团队培养及环境准备关键三步”、实现“以患者为中心，医患共享决策”的理论和实践分析多重慢性病管理模式，来探索我国社区多重慢性病的管理策略，为全科医疗行业持续发展提供借鉴和参考。

关键词: 多重慢性病, 社区卫生服务, 全科医疗

CAI Xixuan,WANG Jianbang,WU Jiang, et al. Challenge of Sustainable Development to General Practice in China：Management Strategies for Multiple Chronic Diseases in the Community　[J]. Chinese General Practice, 2020, 23(34): 4279-4284，4290. DOI: 10.12114/j.issn.1007-9572.2020.00.576.
蔡细旋,王建榜,吴江等. 我国全科医疗持续发展的挑战：社区多重慢性病的管理策略[J]. 中国全科医学, 2020, 23(34): 4279-4284，4290. DOI: 10.12114/j.issn.1007-9572.2020.00.576.

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