分级诊疗背景下三级医院专科团队与社区家庭医生联动的全程健康管理模式探索OA

Hierarchical diagnosis and treatment is a significant measure in deepening China's healthcare system reform.During the 13th Five-Year Plan period,China achieved phased successes in this area,which is of great importance for promoting the equalization of basic medical and health services.In response to the collaboration characteristics and existing issues between tertiary hospitals and community health services under the hierarchical medical system,this article proposes recommendations such as exploring the construction of a linkage mechanism between tertiary hospital specialist teams and community family physicians within a full-process health management model,exploring effective incentive mechanisms for such collaboration,establishing a full-process health management platform for contracted family physician services involving tertiary hospital specialist targeting key populations and specific diseases,and promoting the construction of family doctor teams based on a"specialist-general practice"model,so as to further promote the decentralization of high-quality medical resources and enhance residents'perception of contracted family physician services.