Development of the Chronic Disease Management Team Consisting Mainly of Specialists and General Practitioners from the Institutions of a Medical Consortium and Its Role in the Implementation of the Hierarchical Medical System

doi:10.12114/j.issn.1007-9572.2018.34.004

Abstract

Abstract: The distribution of medical resources in China is imbalanced nowadays. Most high-quality medical resources are distributed in tertiary hospitals，but not in primary healthcare institutions. Insufficient resources hinder primary healthcare institutions from playing their due role in promoting the development of the hierarchical medical system，to satisfy the health needs of residents. Therefore，the supply-side reform in pharmaceutical and healthcare fields is imperative. The "Healthy China 2030" Planning Outline put forward goals for realizing the innovation of the patterns of healthcare provision and achieving a mature and sound hierarchical medical system in an all-round way. The construction of a medical consortium is a way to promote the development of hierarchical medical system by integrating the local medical resources and allocating high-quality resources to primary care using a guided approach. We analyzed the structure of chronic disease management teams of medical consortium of Beijing Chao-Yang Hospital，Capital Medical University，consisting mainly of specialists from general hospitals，general practitioners and health managers from community healthcare institutions，detailed the teams' delivery process of contracted family doctor services，summarized the teams' features and positive role in promoting the development of hierarchical medical system，with a view to providing a reference for facilitating the full implementation of this system.

Key words: Medical health alliance, Hierarchical medical system, Chronic disease management, Specialist physicians-general practitioners combination

摘要： 目前，我国医疗资源分配不均衡，优质资源多集中于三级医院，导致分级诊疗难以落实到位，无法满足人民群众对健康的高要求，因此医药卫生领域的供给侧改革势在必行。《“健康中国2030”规划纲要》提出创新医疗卫生服务供给模式，全面建立成熟完善的分级诊疗制度。医联体模式可以通过整合内部医疗资源，引导优质资源下沉，进而实现分级诊疗的目标。本文以首都医科大学附属北京朝阳医院医联体的“专全结合”慢性病管理团队为例，介绍了团队内的综合医院专科医师、社区医院全科医生及健康管理师如何开展医联体特色的家庭医生式签约服务，并分析其特点和积极作用，为分级诊疗的全面实施提供参考。

关键词: 医联体, 分级诊疗, 慢性病管理, 专全结合

CHENG Jie,XU Xiangtian,WANG Zhe, et al. Development of the Chronic Disease Management Team Consisting Mainly of Specialists and General Practitioners from the Institutions of a Medical Consortium and Its Role in the Implementation of the Hierarchical Medical System[J]. Chinese General Practice, 2018, 21(34): 4178-4182. DOI: 10.12114/j.issn.1007-9572.2018.34.004.
程洁,徐向天,王哲等. 医联体“专全结合”慢性病管理模式及其对开展分级诊疗的作用研究[J]. 中国全科医学, 2018, 21(34): 4178-4182. DOI: 10.12114/j.issn.1007-9572.2018.34.004.

References

［1］刘国恩，官海静.分级诊疗与全科诊所：中国医疗供给侧改革的关键［J］.中国全科医学，2016，19（22）：2619-2624.DOI：10.3969/j.issn.1007-9572.2016.22.001.
LIU G E，GUAN H J.Hierarchical diagnosis and treatment and general practice clinics：key of China's health supply-side reform［J］.Chinese General Practice，2016，19（22）：2619-2624.DOI：10.3969/j.issn.1007-9572.2016.22.001.
［2］李玲.分级诊疗的基本理论及国际经验［J］.卫生经济研究，2018，35（1）：7-9.DOI：10.14055/j.cnki.33-1056/f.20180109.019.
LI L.The basic theory and international experience of graded diagnosis and treatment system［J］.Health Economics Research，2018，35（1）：7-9.DOI：10.14055/j.cnki.33-1056/f.20180109.019.
［3］国务院办公厅关于印发全国医疗卫生服务体系规划纲要（2015—2020年）的通知［Z］.2015.
［4］国家卫生健康委员会.2018年2月底全国医疗卫生机构数［EB/OL］.（2018-04-26）［2018-07-10］.http：//www.moh.gov.cn/mohwsbwstjxxzx/s7967/201804/4aa0d800421c490fbc2494a0b9072fa7.shtml.
［5］国家卫生健康委员会.2018年2月全国医疗服务情况［EB/OL］.（2018-04-27）［2018-07-10］.http：//www.moh.gov.cn/mohwsbwstjxxzx/s7967/201804/fbdc2c5759754be5b4c2e1709db66a3f.shtml.
［6］国务院办公厅关于推进分级诊疗制度建设的指导意见［Z］.2015.
［7］吴三兵，胡焱，辛昌茂，等.分级诊疗制度的实质与我国分级诊疗制度建设的出路［J］.中华医院管理，2016，32（7）：485-487.DOI：10.3760/cma.j.issn.1000-6672.2016.07.002.
WU S B，HU Y，XIN C M，et al.Hierarchical medical system：implications and future direction［J］.Chin J Hosp Admin，2016，32（7）：485-487.DOI：10.3760/cma.j.issn.1000-6672.2016.07.002.
［8］蔡利强，侯进，陆新建.香港转诊制度对内地实施分级诊疗的启示［J］.中国全科医学，2017，20（15）：1787-1792，1797.DOI：10.3969/j.issn.1007-9572.2017.15.001.
CAI L Q，HOU J，LU X J.Enlightenment of the implementation of patient referral system in Hong Kong to the carrying out of hierarchical medical system in the mainland of China［J］.Chinese General Practice，2017，20（15）：1787-1792，1797.DOI：10.3969/j.issn.1007-9572.2017.15.001.
［9］北京市卫生和计划生育委员会.北京医药分开综合改革一周年新闻发布会［EB/OL］.（2018-04-20）［2018-10-02］.http：//wjw.beijing.gov.cn/sy/sydt/201804/t20180420_238696.htm.
［10］方鹏骞，李曼琪，李文敏.试论三级公立医院在医联体中的引领作用［J］.中国医院管理，2018，38（5）：1-3.
FANG P Q，LI M Q，LI W M.Analysis of the leading role of tertiary public hospitals in medical alliance［J］.Chinese Hospital Management，2018，38（5）：1-3.
［11］国务院办公厅关于推进医联体建设和发展的指导意见［Z］.2017.
［12］杨森，王朝昕，金花，等.基于利益相关者的上海市分级诊疗现状系统评价［J］.中国全科医学，2018，21（22）：2672-2678.DOI：10.12114/j.issn.1007-9572.2018.22.006.
YANG S，WANG C X，JIN H，et al.Assessment of the implementation of hierarchical medical system in Shanghai from a multi-stakeholder perspective：a systematic review［J］.Chinese General Practice，2018，21（22）：2672-2678.DOI：10.12114/j.issn.1007-9572.2018.22.006.
［13］黄亦恬，陶红兵，江恬雨，等.医联体实现条件与关键问题探讨［J］.中国医院管理，2018，38（9）：4-7.
HUANG Y T，TAO H B，JIANG T Y，et al.Discussion on the preconditions and key issues of medical alliance［J］.Chinese Hospital Management，2018，38（9）：4-7.
［14］王荣英，张金佳，赵稳稳，等.综合性三级甲等医院全科医学科在双向转诊中的作用研究［J］.中国全科医学，2018，21（7）：769-773.DOI：10.3969/j.issn.1007-9572.2018.07.004.
WANG R Y，ZHANG J J，ZHAO W W，et al.The role of general medical department in general three-level hospital in two-way referral［J］.Chinese Journal Practice，2018，21（7）：769-773.DOI：10.3969/j.issn.1007-9572.2018.07.004.
［15］孙俊杰，李双庆.综合性三级甲等医院全科门诊患者就诊体验及影响因素研究［J］.中国全科医学，2018，21（7）：774-777.DOI：10.3969/j.issn.1007-9572.2018.07.005.
SUN J J，LI S Q.Study on the experience and influencing factors of outpatients in general three-level hospitals［J］.Chinese Journal Practice，2018，21（7）：774-777.DOI：10.3969/j.issn.1007-9572.2018.07.005.
［16］于德华，潘莹，张斌，等.三级医院中全科医学的定位和作用［J］.中华全科医学，2016，14（7）：1061-1063.DOI：10.16766/j.cnki.issn.1674-4152.2016.07.001.
YU D H，PAN Y，ZHANG B，et al.Location and role of general practice in tertiary hospital［J］.Chinese Journal of General Practice，2016，14（7）：1061-1063.DOI：10.16766/j.cnki.issn.1674-4152.2016.07.001.

[1]	YAN Fanghong, PENG Guotian, ZHANG Guoli, SUN Ruiyi, MA Yuxia, HAN Lin. Matching Analysis of the Content of Chronic Disease Management for the Elderly in Medical Union: Based on the Perspective of "Guidance-Practice-Need" [J]. Chinese General Practice, 2025, 28(25): 3119-3126.
[2]	BAI Xue, CHEN Qianqian, LI Jie. Innovative Practices in Chronic Disease Management: a New Model for Generalist-Specialist Combination Management of Diabetes and Metabolic Dysfunction-associated Fatty Liver Disease [J]. Chinese General Practice, 2025, 28(23): 2841-2845.
[3]	LI Liqing, YANG Sule, ZENG Chuanmei. Analysis of the Evolution Path and Development Trend of Research Hotspots in Chronic Disease Management in China [J]. Chinese General Practice, 2025, 28(19): 2321-2329.
[4]	LI Wanyu, FU Qiangqiang, JIN Hua, YU Dehua. Analysis of Health Literacy Levels and Influencing Factors of Chronic Disease Patients under Active Health Perspective [J]. Chinese General Practice, 2025, 28(11): 1315-1319.
[5]	WANG Shuyun, LIANG Xia, LI Xia, LIN Lin, FENG Qiming, HUANG Zhaoquan. The Research Hotspots and Frontiers of County-level Medical Community in China [J]. Chinese General Practice, 2025, 28(01): 83-88.
[6]	YAN Wenxin, HU Jian, ZENG Huatang, LIU Min, LIANG Wannian. The Application of Large Language Models in Primary Healthcare Services and the Challenges [J]. Chinese General Practice, 2025, 28(01): 1-6.
[7]	ZHAO Yuling, GU Zhengping, ZHANG Xueying. Progress and Challenges in the Integration of Treatment and Prevention of Chronic Non-communicable Diseases [J]. Chinese General Practice, 2024, 27(31): 3953-3957.
[8]	YANG Sen, ZHAO Huaxin, GE Xuhua, MA Le, JIN Hua, XIE Mujin, PU Zhen, BAI Zhaohui, YU Dehua. Impact of an Integrated Hospital-community-patient Chronic Disease Management Pathway on Postoperative Colorectal Cancer Patients [J]. Chinese General Practice, 2024, 27(22): 2724-2730.
[9]	ZHAI Jiayi, LU Yuan, TAO Qiongying, HUANG Wuquan, LIU Yalin, YU Dehua. A Study on the Factors Influencing Performance of Chronic Disease Management among Population with Mild Cognitive Impairment in the Context of Family Doctor Service Based on Grounded Theory [J]. Chinese General Practice, 2024, 27(13): 1608-1615.
[10]	WANG Yao, QIN Tingting, GU Mingyu, BAI Xinyuan, QIAO Kun, YANG Yutong, LI Xingming. Implementation Status, Problem Analysis, and Policy Recommendations of Hypertension Management in Primary Care in China from the Perspective of Health System Based on Semi-structured Interview [J]. Chinese General Practice, 2024, 27(13): 1544-1549.
[11]	LIU Shuyan, YAO Mi, ZHANG Jiawei, QI Zhennan, QI Jianguang, XIAN Junfang, CHI Chunhua. Policy Analysis on Children's Hierarchical Medical System between Beijing and Shenzhen [J]. Chinese General Practice, 2024, 27(13): 1550-1555.
[12]	NIU Luyao, YING Xinyu, ZHANG Shuqin, AN Zhixin, JI Jingya, LIU Yuehua, GAO Yuexia. Practice and Reflection on Diabetes Community Management Model from the Perspective of Value Co-creation [J]. Chinese General Practice, 2024, 27(05): 563-569.
[13]	SHI Bowen, MA Huimin, PAN Yanzhi, MA He, YANG Chen, XIONG Juyang. Bibliometric Analysis of Advances in mHealth Technology Application in Chronic Disease Management [J]. Chinese General Practice, 2024, 27(04): 485-492.
[14]	LYU Bo, MENG Kai. Can Government Health Expenditures Influence Patients' Choice of Medical Care: an Empirical Study Based on the Suburbs of Beijing [J]. Chinese General Practice, 2024, 27(04): 420-426.
[15]	YAO lin, SHANG Danmei, ZHAO Hui, LIU Xinyu, LIU Yongwei, JIANG Yong. The Effect and Satisfaction of Mobile Network in the Hypertension Management of Community-dwelling Older Adults [J]. Chinese General Practice, 2024, 27(01): 85-90.