Construction of integrated management system of informationalized chronic disease rehabilitation for the disabled elderly in Hebei Province

doi:10.3877/cma.j.issn.2096-0263.2022.01.009

Abstract

Abstract:

With the arrival of aging society in China, the elderly have become the key target population of chronic disease rehabilitation. Among them, the probability of the disabled elderly suffering from chronic diseases is much higher than ordinary elderly and the number is increasing, and the demand for chronic disease rehabilitation services is more urgent. However, under the background of the combination of medical care and nursing and the sinking of resources, the management system of chronic disease rehabilitation for the disabled elderly at grassroots level has not been perfected, and it faces difficulties and obstacles in the aspects of department collaboration, hospital integration, platform docking, and talent training. Therefore, with the help of intelligent means, to seek integrate multiple departments and hospitals effective resources, and to establish the platform of both online and offline services, we explore a whole process integration management mode and hospital to community to home chronic disease rehabilitation integrated management system for the disabled elderly, which makes county-level hospital as the core. The system helps relieve social and family pressure. Taking Qinghe County of Hebei Province as an example, this paper expounds the operation mechanism of the informationalized whole-process integrated management system of chronic disease rehabilitation for the disabled elderly, and puts forward policy suggestions for Hebei Province.

Key words: Disabled elderly, Chronic rehabilitation, Informatization, Whole process, Integration

Yingxian Kang, Yuehua Liu, Jie Geng, Xuewen Liu, Yanrong Sun. Construction of integrated management system of informationalized chronic disease rehabilitation for the disabled elderly in Hebei Province[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2022, 08(01): 54-59.

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模型元素	描述
慢病康养	慢病管理、医中有养、养中有医、机构支撑、居家护理
慢病管理中心	由县级医院牵头成立，涵盖慢病医保、居家护理、残疾康复、公共卫生4部分职能，关联医联体单位、社区、养护院及村卫生室，负责县域失能老年人慢病康养的管理。
慢病管理平台	一项以电子档案为核心的资源共享、数据关联的集约化、一体化管理的信息化平台，为失能老年人提供预约挂号、远程医疗、上下转诊、居家护理持续慢病康养服务。
全流程	包含失能老年人慢性病筛查、诊断和治疗、护理和康复、随诊等全部环节。
融合	分为"四个融合"，一是医保局、卫健局、民政局融合协作；二是公共卫生、慢病医保、居家护理、残疾康复资金融合使用；三是县、乡、村三级医疗机构融合管理；四是慢病管理平台与医疗机构信息系统融合对接。
医疗服务小组	包括医师、护师、药师、营养师、康复师、老年照护师、信息管理师等专业化人员，实施集成化培训，定向签约，负责失能老年人慢性康养具体工作。

模型元素	描述
慢病康养	慢病管理、医中有养、养中有医、机构支撑、居家护理
慢病管理中心	由县级医院牵头成立，涵盖慢病医保、居家护理、残疾康复、公共卫生4部分职能，关联医联体单位、社区、养护院及村卫生室，负责县域失能老年人慢病康养的管理。
慢病管理平台	一项以电子档案为核心的资源共享、数据关联的集约化、一体化管理的信息化平台，为失能老年人提供预约挂号、远程医疗、上下转诊、居家护理持续慢病康养服务。
全流程	包含失能老年人慢性病筛查、诊断和治疗、护理和康复、随诊等全部环节。
融合	分为"四个融合"，一是医保局、卫健局、民政局融合协作；二是公共卫生、慢病医保、居家护理、残疾康复资金融合使用；三是县、乡、村三级医疗机构融合管理；四是慢病管理平台与医疗机构信息系统融合对接。
医疗服务小组	包括医师、护师、药师、营养师、康复师、老年照护师、信息管理师等专业化人员，实施集成化培训，定向签约，负责失能老年人慢性康养具体工作。

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