The so-called "three divisions co-management" means that 1 specialists in tertiary hospitals, 1 general practitioners in community health centers and 1 trained health managers form a team to provide customized and continuous diagnosis and treatment services for patients with chronic diseases. The specialist is responsible for defining the diagnosis and treatment plan and teaching and guiding the basic general practitioners; General practitioners are responsible for the implementation and execution of treatment plans, daily monitoring of illness and two-way referral; Health managers pay attention to health education and patient behavior intervention.
Through the close "tripartite cooperation" among large hospitals, CDC and community medical institutions, a three-level platform including the municipal comprehensive management platform for chronic diseases, the sub-platform for chronic diseases management of medical associations (districts) and the sub-platform for chronic diseases management in communities will be established, and the medical team will be composed of specialists, community family doctors and health managers from the third-level hospitals ("three divisions co-management"), and residents (patients) will be jointly managed by the third-level hospitals and community hospitals.
Generally, it is composed of nurses, laboratory doctors and other medical personnel (mainly nurses). After obtaining the qualification of health manager through national formal training and examination, they can take up their posts and assume the role of health manager.
Health manager is the most important part of the "three subjects" and has three responsibilities: first, to assist specialists and general practitioners to contact patients; The second is to be responsible for the daily follow-up and home visits of patients; The third is to strengthen personalized health education for the masses. It mainly determines the speed and quality of patients' subsequent recovery, and also determines whether they can fundamentally solve the problem and truly maintain stability and health.
The joint management of the three departments not only forms a service model of "combination of medicine and prevention, combination of prevention and treatment", but also solves the problem of patients' trust by "linkage from top to bottom". Attracted by high-quality services, patients with chronic diseases began to consciously seek medical treatment in the community, and were stuck in the community, and the problem of graded diagnosis and treatment was solved.
Effect of joint management of three departments
Xiamen has made great efforts to solve the three key links of "connection" at the grass-roots level, "willingness to release" at the hospital level and "willingness to go" at the patient level, and gradually established a graded diagnosis and treatment system combining internal incentives with external support. After the reform, the basic diagnosis system of chronic diseases in Xiamen was basically established, and the number of visits to primary medical and health institutions accounted for 29.40% of the total outpatient visits of public medical institutions in the city.
20161June, with a year-on-year increase of 54.60%. The statistical analysis of 25,000 patients' follow-up shows that the primary consultation rate of diabetic patients has increased from 40.7% to 78. 1%, and that of hypertensive patients has increased from 72.6% to 95.7%. At the same time, the number of general outpatients in tertiary hospitals began to decline, with a decrease of 6.02% in 20 15 years and 7.82% in 20 16 years10-June. The waiting time for patients to see a doctor decreased from 40 minutes to less than 10 minutes.