First, the basic situation of community health in Zhang Xiang Road
The population of Zhang Xiang Road community is 25 1 13, and the total number of households is 64 15, including floating population. Among the key age groups, there are 0-7 years old children 1 153 people and 792 people aged 60. The occupations of the community population are mostly industrial workers and retirees. According to the statistics of chronic diseases in the community, there are 5 12 patients with hypertension, 0/58 patients with diabetes, 20 patients with chronic bronchitis, 28 patients with heart disease, 0/0 patients with tumor and 0/0 people with disabilities.
Community diseases are common, and the elderly in the community are mainly chronic diseases such as hypertension, diabetes and osteoarthropathy. Residents with chronic diseases generally have insufficient understanding of prevention and treatment. The high risk factors of chronic diseases in residents are: smoking, high salt, high fat, alcoholism, obesity and lack of physical exercise. The resident population in the community is more than 8%, and the population is aging seriously. Community health should be tilted towards the elderly as much as possible.
The cultural structure of the population above community 15: junior high school students 70%, senior high school students 19.5%, college students 10%, and illiterate 0.5%. The average monthly household income is more than RMB 1 100, and the average monthly expenditure is about 550 yuan. Medical insurance for community residents: 75% at their own expense and 25% for urban medical insurance. Residents over 0/5 years old in the community/kloc-do physical exercises such as walking and dancing, accounting for 30% of the total residents.
Second, the guiding ideology
Guided by the spirit of the 17th National Congress of the Communist Party of China, taking the construction of a new urban health service system as the content, focusing on the community health service system and connotation construction project, focusing on improving the service function and enhancing the service capacity, the community health service work in Zhang Xiang Road has been significantly improved.
Three. principle
First, adhere to the government-led and graded responsibility, and strengthen the government's responsibility for community health services.
Second, adhere to the transformation of functions, improve connotation construction, innovate medical operation mechanism, improve efficiency, steadily promote community health services, and strive to improve the quality and level of community health services.
Third, adhere to prevention first, combine prevention with treatment, pay equal attention to Chinese and western medicine, promote health, and strive to meet the growing health needs of residents.
Adhere to the principle of government guidance, departmental cooperation, and participation of medical institutions with various ownership components in community health services.
Adhere to the principle of regional health planning as the guide, making full use of existing health resources as the main body, and combining government investment with resource adjustment.
Adhere to the principle of community-oriented and patient-centered.
Four. target
1. Improve the health level of Zhang Xiang Road community residents, prolong their life and improve their quality of life.
2. Carry out the "three holidays" service mode with overall responsibility, full-time service and full-time care, and provide all-round health services for residents, so as to make Zhang Xiang Road Community one of the healthy communities in Changsha.
3. Promote the construction of spiritual civilization in Zhang Xiang Road community.
4. An efficient, low-consumption, high-quality, low-cost and convenient community health service system to realize "serious illness in the hospital and minor illness in the community".
5, strengthen the construction of talent team, improve the overall quality of community health service institutions, and change the concept in place.
6. Give full play to the "six-in-one" function of "integrating prevention, health care, medical treatment, rehabilitation, health education and family planning technical guidance to provide effective, economical, convenient, comprehensive and sustainable primary health services" and strengthen the connotation construction and capacity building of community health.
7. Establish a "green life channel" for community residents to benefit poor residents.
8. Continue to strengthen the publicity of community health services, increase the content of services, and truly implement the work of community health services, so that the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road 20 14 community residents can reach over 85%, 75% and 80% respectively.
Verb (abbreviation for verb) main job
1. Improve the connotation construction of community health service institutions and high-quality residents' health records, equip with necessary basic equipment, enrich the "six-in-one" service function, increase personnel training, strengthen professional technology, community appropriate technology and management skills training, actively promote Chinese medicine services, and carry out promotional activities such as prevention and treatment of chronic diseases, rehabilitation of disabled people, and health education to continuously improve the quality of community health services. Make the awareness rate of community residents reach more than 85% and enjoy more than 75% services. In 2009, gradually improve the contents of residents' health files, so that the newly added health files in Xiangzhanglu community will reach more than 90% in 20 14 years.
2. Change the concept, update the service mode, take the initiative to carry out on-site service, extended service, continuous service and hospice care service, implement the preferential policies of community health service, specifically implement the "five exemptions and two reductions" (exemption from registration fee, exemption from first visit fee, exemption from injection fee, exemption from health consultation fee, and reduction of hospitalization fee), carry out caring service, and implement family ward and family care. Provide residents with convenient, fast, economical, high-quality and cheap community health services. Community doctors should visit the community for no less than 15 days every month, and the door-to-door service for chronic disease management should be no less than 10 times per person every year.
3. Innovate the operation mechanism, establish a long-term mechanism for community health services, and go deep into communities and families. In this community work plan, we should focus on the elderly, women, pregnant women, children and the disabled, improve the quality of chronic disease management, and carry out good annual health examination. Do a good job in the first consultation system and two-way referral system of community medical care, fully implement the sinking of public health personnel, strengthen the functional orientation and division of responsibilities of community health service institutions, hospitals, centers for disease control and prevention, and maternal and child health centers, strengthen work connection and resource sharing, and actively carry out assistance and guidance and two-way communication to facilitate the people to seek medical treatment nearby and ensure medical safety. The establishment rate of children's insurance card is 100%, the planned immunization rate is 95%, the management rate of pregnant women is 80%, the hospital delivery rate is 95%, and the hospital delivery rate of high-risk pregnant women is 100%.
4. Strengthen personnel management and training, implement on-the-job training for general practitioners and nurses, and community health service institutions should strictly implement the quota training plan, arrange all trainers, and complete the task to the letter. Further standardize medical behavior, actively explore feasible salary distribution schemes, establish a performance appraisal mechanism for community doctors, and implement post responsibility system, target management and quantitative assessment. The assessment results are linked to personal rewards and punishments, which fully mobilize the initiative and enthusiasm of community doctors, and reflect the priority of efficiency, more work and more rewards, rewarding diligence and punishing laziness. Strict community health personnel access system, the implementation of open recruitment, contract employment, establish and improve the resignation system, so as to "support people, can enter and exit."
5. Strengthen supervision and business guidance, implement centralized procurement and unified distribution of drugs, standardize and reduce drug circulation links, reduce drug costs, select basic medical drugs mainly related to common diseases and frequently-occurring diseases in the community, so that residents can enjoy basic cheap services in the community, and strictly implement government procurement of medical equipment.
6, continue to strengthen the publicity of community health and cooperation with relevant departments to improve the awareness rate of community residents; Strengthen information submission, implement computer network management, build community information platform, form a good network of up and down, left and right connection and information sharing, provide scientific basis for community health service, and ensure the comprehensive development of community health work.
7. Promote the establishment of a two-way referral system with superior hospitals. For critically ill patients in the community, they rushed to the scene at the first time and were escorted directly through the green life channel such as the ward, without outpatient registration and consultation; Patients in rehabilitation period will be transferred to the community for rehabilitation in time, and they will go to the center for equipment training regularly. Under the guidance of community service personnel, family members can master some simple and practical skills such as health care, nursing, rehabilitation and massage, so that patients can also carry out rehabilitation activities at home.
8. Promote humanized service. The center insists on taking residents' health as the center and developing community health services with families as the unit. To dynamically detect and manage the health status of community residents, especially the elderly, women and children, and provide humanized services for the needs of special groups.
9. Strengthen standardized management of community health. Strengthen the standardization, standardization and scientific management of community health, gradually establish and improve the basic standards, basic service norms and management methods of community health institutions, and improve various rules and regulations.
10, focusing on the construction of five types of community health service institutions: general practitioner clinic, nursing home for the aged, community rehabilitation center, home care center and diagnosis center.
(1) general practitioner clinic
At the end of 20 14, the coverage rate of general clinics reached 100%, and the general clinics were dynamically managed, and the last one was eliminated, and the annual assessment was conducted to encourage competition among general clinics and ensure the overall quality of general clinics.
(2) Nursing homes
Transform idle and underutilized medical institutions in the community into nursing homes. According to the market demand, nursing homes for the aged will be established to treat the elderly, terminally ill patients and disabled people who need nursing services, and provide a series of services such as treatment, nursing, hospice care, nutritional guidance and psychological consultation.
(3) Community rehabilitation center
Relying on secondary and lower hospitals, equipped with corresponding equipment and personnel, and according to market demand, we will strive to establish 3-5 community rehabilitation centers with reasonable layout to provide comprehensive treatment and auxiliary measures for people with dysfunction caused by diseases and injuries.
(4) Home Care Center
Transform idle and underutilized medical institutions in this area into home care centers. According to the market demand, establish a home care center to undertake community home care and home care services.
(5) Establish a two-way referral system. Guide five types of institutions to sign a "two-way referral agreement" and establish a two-way referral system suitable for all parties. By establishing a two-way referral system, all kinds of community health service institutions will form a system with complete functions, smooth operation and reasonable division of labor.
1 1, strengthen software construction.
(1) personnel training
At the end of 20 14, the participation rate of community health service practitioners in general practice, community nursing, rehabilitation medicine and other related training reached over 90%, and they were certified to work.
(2) Health education
Give full play to the main functions of the health education institute, establish and improve the community health education network, and the network construction rate will reach 100%. Equipped with full-time and part-time health education personnel, strengthen training, the training rate reached more than 80%.
(3) Community intervention of chronic non-communicable diseases, mainly hypertension.
With the cooperation of the municipal and district disease control departments, it will be held on 20 14:
-community/kloc-the annual blood pressure measurement rate of people over 0/5 years old reaches over 60%;
-80% hypertensive patients in the community receive health education and take medicine regularly;
-The per capita salt intake of residents should be controlled below 10g;
-More than 40% residents take part in physical exercise.
(4) maternal and child health care and family planning technical services
Give full play to the functions of maternal and child health care centers, rely on the cooperation of the Family Planning Commission, focus on reproductive health, and actively carry out systematic management of five-level education, five-level health care and child health care for women in communities. As of 20 15:
-Actively carry out systematic health care for pregnant women and basic health care for children, with community coverage rates reaching 65,438+000% and 98% respectively;
-To carry out community nutrition monitoring, intervention and guidance for children, so that the coverage rate of nutrition guidance for children under 5 years old reaches 98%;
-Carrying out baby-friendly actions, with breast-feeding reaching 85%;
—— Carry out family planning technical services, and the pregnancy management rate of floating population will reach100%;
-The coverage rate of five-level health care for women of childbearing age in the whole region has reached 90%.
12, community rehabilitation
Based on the principle of * * * sharing resources and * * * building together * * *, we will fully mobilize and make good use of various resources in the community, establish a number of community rehabilitation stations with district rehabilitation centers as the main body and the Disabled Persons' Federation and other relevant departments, and rely on the community to carry out community rehabilitation by using simple rehabilitation equipment and traditional Chinese medicine means.
13, standardization construction of community health service institutions
-Strict examination and approval of health-related products, strengthening the examination and approval of community medical institutions, community practicing doctors, community practicing nurses and medical technology applications;
-resolutely crack down on illegal community doctors, ban unlicensed medical practice, and rectify counterfeit community health service institutions such as out-of-scope medical practice;
-Promote the moral construction of the health system to extend to the community and establish a good image of community medical workers among the people.
Working steps of intransitive verbs
In accordance with the principle of implementation year by year and decentralized promotion, on the basis of doing a good job in daily routine work, we will do a good job in key tasks every year.
1, 20 10 work focus
(1) Start the community health work plan.
(2) Start to improve residents' health records and establish a "green life channel" for community residents to benefit poor residents. Implement the "three-all" service model of overall responsibility, full service and full care.
(3) By the end of 20 1 1, the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road community residents reached 8 1%, 7 1% and 75% respectively.
(4) change the concept, update the service mode, take the initiative to carry out on-site service, extended service, continuous service and hospice care service, implement the preferential policies of community health service, and specifically implement the "five exemptions and two reductions" (exemption from registration fee, exemption from first consultation fee, exemption from injection fee, exemption from health consultation fee, hospitalization fee reduction and hospitalization fee reduction), carry out caring service, and promote family wards and familyization. Provide residents with convenient, fast, economical, high-quality and cheap community health services. Community doctors should visit the community for no less than 15 days every month, and the door-to-door service for chronic disease management should be no less than 10 times per person every year.
(5) Standardized construction of community health service institutions
(6) Strengthen efforts to establish a good general practitioner clinic.
2, 20 1 1 work focus
(1) Innovate the operation mechanism, establish a long-term mechanism for community health services, and go deep into communities and families. In this community work plan, we should focus on the elderly, women, pregnant women, children and the disabled, improve the quality of chronic disease management, and carry out annual health checkups. Do a good job in the first consultation system and two-way referral system of community medical care, fully implement the sinking of public health personnel, strengthen the functional orientation and division of responsibilities of community health service institutions, hospitals, centers for disease control and prevention, and maternal and child health centers, strengthen work connection and resource sharing, and actively carry out assistance and guidance and two-way communication to facilitate the people to seek medical treatment nearby and ensure medical safety. The establishment rate of children's insurance card is 100%, the planned immunization rate is 95%, the management rate of pregnant women is 80%, the hospital delivery rate is 95%, and the hospital delivery rate of high-risk pregnant women is 100%.
(2) By the end of 20 1 1, the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road community residents reached over 82%, 72% and 76% respectively.
(3) Focus on the construction of nursing homes for the aged.
(4) to carry out community health service practitioners to participate in general practice, community nursing, rehabilitation medicine and other related training.
3, 20 12 work priorities
(1) Strengthen personnel management and training, implement on-the-job training for general practitioners and nurses, and community health service institutions should strictly implement the quota training plan, arrange all trainers, and complete the task to the letter. Further standardize medical behavior, actively explore feasible salary distribution schemes, establish a performance appraisal mechanism for community doctors, and implement post responsibility system, target management and quantitative assessment. The assessment results are linked to personal rewards and punishments, which fully mobilize the initiative and enthusiasm of community doctors, and reflect the priority of efficiency, more work and more rewards, rewarding diligence and punishing laziness. Strict community health personnel access system, the implementation of open recruitment, contract employment, establish and improve the resignation system, so as to "support people, can enter and exit."
(2) By the end of 20 12, the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road community residents reached over 83%, 73% and 77% respectively.
(3) Focus on building community rehabilitation centers. Give full play to the main functions of the health education institute, establish and improve the community health education network, and the network construction rate will reach 100%. Equipped with full-time and part-time health education personnel, strengthen training, the training rate reached more than 80%.
4, 20 13 work priorities
(1) Strengthen supervision and business guidance, implement centralized procurement and unified distribution of drugs, standardize and reduce drug circulation links, reduce drug costs, select basic medical drugs mainly related to common diseases and frequently-occurring diseases in the community, so that residents can enjoy basic cheap services in the community, and strictly implement government procurement of medical equipment.
(2) Continue to strengthen the publicity of community health and cooperation with departments to improve the awareness rate of community residents; Strengthen information submission, implement computer network management, build community information platform, form a good network of up and down, left and right connection and information sharing, provide scientific basis for community health service, and ensure the comprehensive development of community health work.
(3) By the end of 20 13, the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road community residents reached over 84%, 74% and 78% respectively.
(4) Community intervention of chronic non-communicable diseases, mainly hypertension.
With the cooperation of the municipal and district disease control departments, it will be held on 20 14:
-community/kloc-the annual blood pressure measurement rate of people over 0/5 years old reaches more than 50%;
-75% patients with hypertension in the community receive health education and take medicine regularly;
-the per capita salt intake of residents should be controlled below 1 1g;
-More than 35% residents take part in physical exercise.
(5) Focus on the construction of home care centers.
5, 20 14 work priorities
(1) Promote the establishment of a two-way referral system with superior hospitals, so that critically ill patients in the community can arrive at the scene at the first time and be directly escorted to the ward through the green life channel without outpatient registration and consultation; Patients in rehabilitation period will be transferred to the community for rehabilitation in time, and they will go to the center for equipment training regularly. Under the guidance of community service personnel, family members can master some simple and practical skills such as health care, nursing, rehabilitation and massage, so that patients can also carry out rehabilitation activities at home.
(2) Advocating humanized service. The center insists on taking residents' health as the center and developing community health services with families as the unit. To dynamically detect and manage the health status of community residents, especially the elderly, women and children, and provide humanized services for the needs of special groups.
(3) Strengthen the standardized management of community health. Strengthen the standardization, standardization and scientific management of community health, gradually establish and improve the basic standards, basic service norms and management methods of community health institutions, and improve various rules and regulations.
(4) By the end of 20 14, the awareness rate, service utilization rate and service satisfaction rate of Zhang Xiang Road community residents reached 85%, 75% and 80% respectively.
(5) Community intervention of chronic non-communicable diseases, mainly hypertension.
With the cooperation of the municipal and district disease control departments, it will be held on 20 14:
-community/kloc-the annual blood pressure measurement rate of people over 0/5 years old reaches over 60%;
-80% hypertensive patients in the community receive health education and take medicine regularly;
-The per capita salt intake of residents should be controlled below 10g;
-More than 40% residents take part in physical exercise.
(6) maternal and child health care and family planning technical services
Give full play to the functions of maternal and child health care centers, rely on the cooperation of the Family Planning Commission, focus on reproductive health, and actively carry out systematic management of five-level education, five-level health care and child health care for women in communities. As of 20 14:
-Actively carry out systematic health care for pregnant women and basic health care for children, with community coverage rates reaching 65,438+000% and 98% respectively;
-To carry out community nutrition monitoring, intervention and guidance for children, so that the coverage rate of nutrition guidance for children under 5 years old reaches 98%;
-Carrying out baby-friendly actions, with breast-feeding reaching 85%;
-technical services for family planning have been carried out, and the pregnancy management rate of floating population has reached 100%.
-The coverage rate of five-level health care for women of childbearing age in the whole region has reached 90%.
Seven. guarantee
Ensure the necessary capital investment in community health services. Community health service integrates prevention, medical treatment, health care, rehabilitation, health education and family planning technical guidance, including many low-paid and unpaid jobs. For this kind of work, we should ensure the necessary economic input and increase financial input to ensure the healthy development of community health services. The government should increase financial input.
(two) to speed up the process of urban medical and health system reform, straighten out various relations, implement various policies, and create a good internal and external environment for the development of community health services.
(3) Promote policy guarantee. Fully implement the provincial, municipal and district "Decision on Accelerating the Development of Urban Community Health Services" and the spirit of its supporting documents, improve the corresponding policies and supporting funds of the provinces, municipalities and districts, increase public health funding, strengthen institutional construction and personnel training, formulate practical operation plans, and incorporate all community health services into designated institutions of social medical insurance to provide strong support and policy guarantee for promoting the development of community health services.