Abstract: Background　Community health service centers （CHSC） shoulder greater responsibility of chronic diseases management as the diabetes incidence in China continues to rise. CHSC，however，can hardly meet the need of diabetes prevention due to its inadequate development. Only by collaborating with higher level hospitals，CHSC can maximize their function of disease prevention and treatment. Objective　To provide reference for improving collaborative health management of diabetes in CHSCs and promoting sound development of family doctor contracted services by virtue of investigation and analysis of current situations，demand and shortcomings of collaborative primary health management of diabetes in CHSC in Wuhou District，Chengdu City. Methods　Six community health service centers in downtown areas and outskirts of Wuhou District，Chengdu City have been selected through purpose sampling method. Medical staff and diabetic patients were randomly selected from each of the six CHSC. The research team conducted a survey in January 2018 with a self-designed questionnaire consisting of questions for medical staff，including implementation of collaborative health service pattern，frequency of use，willingness of use，degree of satisfaction，problems and demand，and questions for diabetic patients，including awareness，satisfaction，necessity，problems of this service and further needs. Results　All selected CHSC conducted two-way referral. Every three centers set up joint specialty-general practice clinics. They implemented periodical assessment，remote consultations and remote group consultations. Among 100 medical staff in these CHSC，two-way referral had the highest frequency of use （67.0%，67/100）；84 （84.0%） medical staff were more willing to choose two-way referral in their daily work；74 （74.0%） medical staff were relatively satisfied with two-way referral. Among 140 diabetic patients in this study，82 （58.6%） of who acknowledged the necessity of and were satisfied with two-way referral；51 （36.4%） patients acknowledged the necessity of and were satisfied with remote consultation service；36 （25.7%） patients acknowledged and were satisfied with periodical assessment；68 （48.6%） patients acknowledged the necessity of and were satisfied with joint specialty-general practice clinics. Conclusion　Most diabetic patients are not clear about collaborative health management of diabetes in CHSCs There are problems such as poor two-way referral process and insufficient service capacity of medical staff. We can better meet the need of patients via improving information platform of the collaborative service，strengthening the coordination between CHSC and higher-level hospitals and enhancing the service capability of staff.

Key words: Diabetes mellitus, Health management, Collaborative service, Community health centers

摘要： 背景　我国糖尿病发病率持续增长，社区卫生服务中心肩负着慢性病管理重任。但社区卫生服务中心因发展滞后，导致后续动力不足，难以满足糖尿病防病形势的需要。因此基层医院结合上级医院的协同才能发挥最大的防治作用。目的　通过调查分析成都市武侯区基层糖尿病健康管理协同服务现况及需求，探求问题和不足，为改善基层糖尿病健康管理协同服务能力，促进家庭医生签约服务良性发展提供参考依据。方法　采用目的抽样法抽取成都市武侯区中心城区及城乡结合部等6家社区卫生服务中心，并在每个社区卫生服务中心采用随机抽样法抽取基层医务人员和糖尿病患者，于2018年1月采用自行设计的糖尿病协同服务相关的调查问卷进行调查，包括基层医务人员对协同服务方式的开展情况、使用频率、使用意愿、满意情况、存在的问题及需求等，糖尿病患者对协同服务方式的知晓、满意、开展的必要性、存在的问题及需求等。结果　社区卫生服务中心均开展了双向转诊，平均3个社区卫生服务中心设立了专-全科联合门诊、周期性评估、远程咨询和远程会诊。100例基层医务人员中，使用频率最高的是双向转诊（67.0%，67/100），84例（84.0%）基层医务人员在日常工作中更愿意选择双向转诊，74例（74.0%）基层医务人员对双向转诊较满意。140例糖尿病患者中，82例（58.6%）糖尿病患者对双向转诊知晓、满意且认为开展有必要，51例（36.4%）糖尿病患者对远程会诊知晓、满意且认为开展有必要，36例（25.7%）糖尿病患者对周期性评估知晓、满意且认为开展有必要，68例（48.6%）糖尿病患者对专-全科联合门诊知晓、满意且认为开展有必要。结论　大部分糖尿病患者对基层卫生服务机构的协同服务内容不清楚，存在转诊流程不通畅以及基层医务人员服务能力不足等问题，可通过完善协同服务的信息平台、加强基层与上级医院协调、提高全科团队服务能力等方式，满足糖尿病患者的协同服务需求。

关键词: 糖尿病, 健康管理, 协同服务, 社区卫生中心