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The community proactive health management model based on liaison and family doctor: The case of Shandong, China
Abstract
Objective To establish a proactive health management model based on the grid-based medical service team, and to explore the effect of this model on managing chronic diseases in community health service institutions. Methods A grid-based medical service team was established in Binzhou, Shandong, consisting of general practitioners, nurses, public health doctors, health promoters, and community grid liaison. Each team was responsible for several grid areas to track critical populations within the grid and compile statistics on the health management of key populations in 2022-2023. Results A total of 2050 patients with coronary heart disease, 4973 patients with hypertension, and 1621 patients with type 2 diabetes were followed up in 2022. Compared with 155,612 resident health records in 2022, the records increased by 140.50% in 2023. The number of hypertension patients under health management in 2023 increased by 50.92%; patients with type 2 diabetes increased by 74.65%; and the number of coronary heart disease increased by 42.00%. After the implementation of grid management, the hospitalization rate of patients with diabetes mellitus significantly decreased in 2023 (p<0.05). However, the hospitalization rate of patients with coronary heart disease and hypertension patients exhibited a similar hospitalization rate in 2023 compared to those in 2022 (p>0.05). Conclusion The grid-based community proactive health management model gives full play to the advantages of community resources and improves the pertinence and coverage of community health services. Moreover, it reduces hospitalization for type 2 diabetes.
PY24030 Accepted 11 June 2024
© La Trobe University 2024
