Abstract: Home care is one type of essential services included in primary care services. Various family-related factors，interaction between family members and family resource utilization are important for disease incidence，treatment and rehabilitation of a family member. So it is necessary for a general practitioner（GP） to pay attention to the patient's family-related factors besides the health problem when delivering diagnosis and treatment services clinically. To explore the benefits of home care via follow-up investigation as useful evidence，we analyzed the data of home care for a case obtained by home follow-ups. The analysis indicates that by home follow-up assessment of the patient and his family，family resource management and family management，GPs may identify the potential family health risks，effectively address family health problems，and reduce the possibility of the patient having an adverse event. Moreover，long-term continuous home follow-ups and patient's positive feedback of interventions may also facilitate the solving of family health problems，and the building and strengthening of a good patient-physician relationship. Furthermore，home follow-up has been proved applicable for community care as a flexible and efficient consultation way.

Key words: General practice, Family-based care, Home visits, General practitioners, Primary health care

摘要： 对家庭的照顾是全科医学的核心特征之一，家庭中各种因素、家庭成员间的相互作用关系及家庭资源的利用等对患者患病、治疗和康复具有重要意义，因此，全科医生在临床诊疗中，在考虑患者个人健康问题的同时，还需关注患者的家庭。本文的主要目的是探讨通过家庭访视实施以家庭为单位的健康照顾在全科诊疗中的优势，以期为全科医生进行全家庭照顾提供参考。本文从1例“评估性家庭访视”案例出发，全科医生通过深入患者家庭、进行个人评估和家庭评估、协调家庭内外部资源及全家庭管理，可快速识别家庭中的安全隐患，有效解决家庭问题，减少生活不良事件的发生。通过长期、连续性随访及对干预效果的不断正反馈，全科医生见证了家庭问题日益得到改善，巩固了良好的医患关系。可见，家庭访视是一项灵活而高效的诊疗服务，具有很高的实用价值，适用于基层医疗卫生机构在社区环境中开展。

关键词: 全科医学, 以家庭为单位的照顾, 家庭访视, 全科医生, 基层卫生保健