In order to promote the hierarchical diagnosis and treatment system and the construction of healthy China, the General Office of the State Council clearly pointed out that a medical community should be established in the county. Zhejiang Province took the lead in exploring the integrated outpatient service of chronic diseases in the construction of medical community. At present, the research on the integrated outpatient service of chronic diseases in China mainly focuses on the discussion of concepts, and less quantitative research is carried out on the current situation of services.

To analyze the current situation of the integrated outpatient service of chronic diseases in county medical communities in Zhejiang Province and explore its influencing factors, so as to provide countermeasures and suggestions for improving the operation of the integrated outpatient service of chronic diseases.

From October to November 2023, using the typical sampling method and taking into account the principle of geographical balance, 18 community health service centers/township hospitals under 6 medical communities in Linping District of Hangzhou, Yuhuan City of Taizhou, Jiangshan City of Quzhou and Jiashan County of Jiaxing in Zhejiang Province were selected, and outpatients were intercepted at the outpatient waiting offices of corresponding institutions as the research objects. A self-designed questionnaire was used to investigate the patients' evaluation of integrated outpatient services for chronic diseases. The evaluation content involved three aspects: service category, service approach and team building.

A total of 540 questionnaires were distributed and 510 valid questionnaires were recovered, with an effective recovery rate of 94.4 %. The overall score of patients' integrated outpatient service for chronic diseases was (4.4±0.5) points, and the scores of each service category were: pre-diagnosis service (4.4±0.5) points, in-diagnosis service (4.3±0.5) points, and post-diagnosis service (4.1±0.6) points. The average score of each item in the service approach dimension was ≥3.7 points, and the average score of each item in the service team building dimension was ≥3.9 points. The results of multiple linear regression analysis showed that factors such as age, education, monthly income, whether the overall medical services of the hospital could meet their own needs, and satisfaction with the hospital 's diagnosis and treatment environment would have an impact on the evaluation of the development of integrated outpatient clinics for chronic diseases (P<0.05) .

The current situation of integrated outpatient services for chronic diseases in county medical communities in Zhejiang Province is generally good, but there is still room for improvement in post-diagnosis services, service channels, and overall medical services. The primary medical and health institutions in Zhejiang Province should pay attention to the continuity of post-treatment services, strengthen the integrated outpatient service mode and team building of chronic diseases, promote the development of medical services in a diversified and high-quality direction, and enhance the residents' sense of medical experience.

为推动分级诊疗制度和健康中国建设，国务院办公厅明确指出要在县域组建医疗共同体，浙江省在医共体建设中率先进行了慢性病一体化门诊的探索，而目前国内关于慢性病一体化门诊的研究主要集中在概念探讨，针对服务现状开展的定量研究较少。

了解浙江省县域医共体慢性病一体化门诊服务开展现状并探究其影响因素，为完善慢性病一体化门诊运行提供对策建议。

于2023年10—11月，采用典型抽样法兼顾地理位置均衡原则，选取浙江省杭州临平区、台州玉环市、衢州江山市、嘉兴嘉善县4个地区的6家医共体下的18家社区卫生服务中心/乡镇卫生院，在相应机构门诊候诊处拦截门诊患者。采用课题组自设问卷调查患者对慢性病一体化门诊服务的评价，评价内容涉及服务类别、服务途径及团队建设3方面。

共发放问卷540份，回收有效问卷510份，问卷有效回收率为94.4%。患者对慢性病一体化门诊服务的总体评分为（4.4±0.5）分，对诊前服务的评分为（4.4±0.5）分，对诊中服务的评分为（4.3±0.5）分，对诊后服务的评分为（4.1±0.6）分，对服务途径维度各条目的平均评分均≥3.7分，对服务团队建设维度各条目的平均评分均≥3.9分。多元线性回归分析结果显示，年龄、学历、月收入、对医院诊疗环境的满意度、对医院总体医疗服务能否满足自身需求的满意度是患者对慢性病一体化门诊服务评分的影响因素（P<0.05）。

浙江省县域医共体慢性病一体化门诊服务开展现状整体较好，但在诊后服务、服务途径、总体医疗服务水平上仍有待改进。浙江省基层医疗卫生机构应重视诊后服务的延续性，强化慢性病一体化门诊服务方式与团队建设，促使医疗服务向多元化、高质量方向发展，提升居民就医体验感。