CAJ | 학술논문

目的：分析嘉定区安亭镇以“慢性病全程管理”为核心的健康促进模式及其实施效果。方法：采用关键知情人访谈法，并对慢性病管理模式负责人进行问卷调查。结果：安亭镇以“慢性病全程管理”为核心的健康促进模式，在社区层面有健康自我管理小组、家庭医生团队和健康小屋，医院层面建立了慢性病工作室，慢性病的全程管理分级明确，转诊畅通。并加以家庭医生管理和信息技术支持等配套措施。此外，从家庭、社区、单位三个层面进行健康促进。由于得到了政府的充分支持，安亭健康促进模式实施后，患者依从性得到提高，同时增加了基层门诊量。结论：安亭镇健康促进模式由政府牵头推进、整合资源，提高了健康管理水平。慢性病管理体系应进一步探索分级诊疗制度。
목적：분석가정구안정진이“만성병전정관리”위핵심적건강촉진모식급기실시효과。방법：채용관건지정인방담법，병대만성병관리모식부책인진행문권조사。결과：안정진이“만성병전정관리”위핵심적건강촉진모식，재사구층면유건강자아관리소조、가정의생단대화건강소옥，의원층면건립료만성병공작실，만성병적전정관리분급명학，전진창통。병가이가정의생관리화신식기술지지등배투조시。차외，종가정、사구、단위삼개층면진행건강촉진。유우득도료정부적충분지지，안정건강촉진모식실시후，환자의종성득도제고，동시증가료기층문진량。결론：안정진건강촉진모식유정부견두추진、정합자원，제고료건강관리수평。만성병관리체계응진일보탐색분급진료제도。
Objective:To analyze the contents and the effectiveness of the health promotion scheme focusing on complete chronic noncommunicable diseases(NCDs) management in Anting town.Methods:Key informant interviews and questionnaire surveys for those who were in charge of NCDs management were adopted.Results:Health self-management groups,general practitioner(GP) teams and health keeping rooms were established in communities. Chronic disease offices were developed in hospitals where the function in NCDs management was clear,the referral was smooth in the scheme and other supporting measures including GP management and information system were well implemented. Besides,health promotion was well conducted in three levels including household,community and workplace. With the support of government,patient compliance and outpatients in primary healthcare institutions were obviously improved after the implementation of the scheme.Conclusion:The health promotion scheme led by Anting government has integrated health and social resources and has improved the level of health management. It is suggested that NCDs management system be further improved through referral system.