Recently, the Shandong Provincial Health and Family Planning Commission issued the "Guidelines for Shandong Province Family Doctor Contract Services (Trial Version)" (hereinafter referred to as "Working Guide"). Today, we take you to focus ~
Family doctor service team formation
The "Working Guide" requires that the family doctor team can determine the method of formation based on the number and ability of the medical staff of the institution and the actual situation. The "3 + X" model composed of family doctors, nurses, and public health physicians (including assistant public health physicians) can be adopted. "X" is the support staff for other cross-team services. You can also adopt the "2 + X" model composed of family doctors and nurses, and use public health physicians or public health personnel as "X" to carry out family doctor team contract services across teams and grids; Chinese medicine doctors can also participate as family doctors Form a core general practice team, and also serve as a specialist physician to provide TCM contracting services across the team as "X".
Family doctors with high professional level and seniority, and very influential among the local people, can establish a family doctor studio named after a personal name to provide contracting services across the grid.
According to the qualifications of team members, with the principle and goal of achieving exclusive integration and hierarchical management, the family doctor team is divided into first-level, second-level and third-level teams. The first-level team is a general-purpose core team composed of general practitioners or rural doctors, community nurses, and public security personnel; the second-level team is a horizontal and comprehensive combination of the first-level team and specialist practitioners (assistants) in primary-level medical and health institutions Team; the third-level team consists of a second-level team and a vertically-integrated and integrated team composed of specialists from the second-level or above medical institutions (medical unions).
The family doctor team implements a team leader responsibility system. The team leader may be a family doctor, a senior community nurse or a person in charge of primary medical and health institutions with administrative experience. Team members have a clear division of labor, work closely together, support each other, and work together to provide services for contracted residents. In principle, each family doctor service team is responsible for 600 families, not more than 800; the number is about 2,000. Each family doctor serves no more than 200 households, and the number is about 600.
The signing team and the residents implement a two-way choice, and the residents choose the service team based on voluntary principles. In the initial stage of implementation, the family doctor team is generally selected according to the grid.
A resident can only sign one team at the same time, encouraging signing nearby, or signing across regions.
When multiple family members living together sign a contract at the same time, try to choose the same family doctor first-level team; if there are special groups among family members, you can sign a second-level and third-level team composed of the first-level team as the core.
The principle of the contract service period is one year, and the residents voluntarily renew, terminate or replace the team when the contract expires.
Design principles for contracted service packages
The contracted service packages can be divided into basic, primary, intermediate and advanced service packages according to different service contents.
Basic service package: With basic public health individual services as the main content, major public health services can be included in the service content in areas with conditions.
Primary service package: According to the different physical conditions, needs and types of medical insurance of the recipients, choose the Chinese and Western medical basic medical projects and basic level suitable for the primary and secondary medical institutions with strong pertinence, high public acceptance, good implementation effect, and the basic medical institutions The technology is included in the contracted service content, and combined into a basic service package of reasonable types, suitable for different people and different diseases.
Intermediate and advanced service packages: Fully consider the public health management service needs and affordability, and further formulate differentiated, menu-based intermediate and advanced service package groups with distinct levels and outstanding features.
Signing service content
The "Working Guide" pointed out that it is necessary to provide residents with comprehensive, continuous, full-range, and comprehensive basic medical, public health, and health management services.
Basic medical services (principle: be a doctor for a minor illness, and a staff member for a serious illness)
Carry out appointment appointments to provide diagnosis and treatment of common diseases, frequently-occurring diseases, and chronic diseases in the community.
Referrals and consultations are given priority to hospitals above the second level.
We will issue "Chronic Prescription" for patients with chronic diseases and enjoy differentiated medical insurance policies.
Provide timely and effective medical consultation and guidance at the agreed time.
Enjoy "Internet +" and health informatization related services.
Public health service
Establish and improve residents' health records, dynamically manage and update, and regularly review and maintain.
According to the actual situation of the residents, provide targeted basic public health services in accordance with the national basic public health service standards.
Other major public health services for residents.
Health management services
Conduct physical health assessments for contracted residents.
According to the health assessment status, provide practical health guidance and risk factor prevention and control measures for contracted residents, and develop personalized health management plans.
Combined with basic public health services, it provides individual health education, follow-up and health management guidance, regular health management effectiveness evaluation, use of health management tools and self-health monitoring guidance.
According to the relevant regulations and the premise of ensuring medical safety, the family doctor team can provide family beds and on-site services within the working hours and capabilities; according to the individual needs of residents, provide personalized medical services.
Signing service process
Signing consultation and publicity → signing service explanation and explanation → health assessment → signing of contract documents → development of health management plan → performance → management assessment → renewal or termination of contract.
Signed Resident Medical Treatment Process
Contracted residents make appointments with family doctors → go to the institution with a card (certificate) → guided diagnosis → preferential treatment to the contracted family doctor → priority treatment → provide national basic public health services → referrals if necessary → improve health records → 1. Personalized health guidance → Help contracted residents to obtain other convenient services brought by the contract → Appoint the next service time → End the consultation.
Referral process between family doctor contract service team and second-level hospitals
In order to promote the first consultation at the grass-roots level, primary-level medical and health institutions have formed a division of labor and cooperative relationship with doctors at and above the second-level hospitals. .
When the patient meets the indications for up- and down-turns specified in the “Working Guide”, he can perform up- and down-turns as required.
Two-way referral flow chart
The family doctor team adopts basic public health and health management services based on population classification, service stratification, and team grading according to the health status of contracted residents.
Family doctors can take various forms to provide services, such as outpatient visits, face-to-face visits, telephone follow-up, telemedicine, and special needs can provide on-site services and out-of-time services.
You can use "Internet +", mobile terminal and information technology to provide contracted residences with services such as online contracting, appointment diagnosis and treatment, waiting reminder, price payment, diagnosis and treatment report query, drug distribution and health information collection, and resident health file query.
Primary medical and health institutions with a large service radius can set up family doctors' studios in neighborhood committees or communities, equipped with certain service facilities, and make appointments to regularly visit the community to facilitate the contracted residents to receive services nearby.
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