Abstract:

The community-based chronic disease containment in China is still in its infancy, and there is a lack of a complete system for practical implementation with tertiary and secondary or primary hospitals collaboratively involved. We systematically summarized the development of chronic disease management in China, then analyzed the essentials of three major foreign chronic disease management models (chronic care model, innovative care for chronic conditions framework, and chronic disease self-management program) and chronic disease management experiences of Finland, the U.S., Australia, Japan with a focus on management ideas, systematic structures, and operable approaches. With these foreign models and experiences as a reference, we developed a general practice plus compact regional medical consortium-based chronic disease management model used in Lishui Town with complexity science and analysis for resource integration, against the backdrop of promoting the development of the compact county medical consortium and contracted family doctor services. We expect that our study could provide new ideas for the research on chronic disease containment in China's primary care.

Key words: Chronic disease, Management model, General practice, Compact county medical community, Complexity science

摘要：

目前我国的慢性病社区防控处于起步阶段，缺乏完整且上下联动的实践体系。本文系统梳理了我国慢性病管理的演变历程，剖析了国外3种主要慢性病管理模式〔慢性病照护模型（CCM）、慢性病创新照护框架（ICCC）、慢性病自我管理计划模型（CDSMP）〕的内涵，以及芬兰、美国、澳大利亚、日本在慢性病防控方面的经验，并从管理理念、系统结构、操作方法等方面总结慢性病管理可借鉴的资源要素。同时，结合我国当前推进的紧密型县域医共体建设和家庭医生签约服务工作，借助复杂性科学理论和分析方法进行资源整合，构建出佛山市里水地区"全科医学+"紧密型医共体慢性病管理模式，以期为我国基层慢性病防控研究提供新思路。

关键词: 慢性病, 管理模式, 全科医学, 紧密型县域医共体, 复杂性科学