In order to give full play to the role of general practitioners as the "gatekeeper" of residents' health, according to the Notice of xx District Health Bureau on Developing the Work Plan of Community Doctors' Contract Service (Li Wei [20xx] 104) and the Notice of XX District Health Bureau on Developing the Work Plan of Rural Doctors' Contract Service (Li Wei [20xx] No.65438+), in order to seriously implement the "promoting development, improving the quality of rural doctors' contract service". Fully embody the advantages and characteristics of family doctor project service, continuously extend and deepen the function and connotation of "six in one" service, provide residents with more convenient, timely, comprehensive and personalized community health services, and gradually establish a long-term and stable service relationship. Based on the actual work of basic public health service projects in our hospital, our main work is summarized as follows.
I. Development situation
(a) attach great importance to and actively deploy.
According to the overall working spirit of the Health Bureau of XX District, a leading group for family doctor contract service in XX Town, headed by President XXX, was established, and a work plan for family doctor contract service in XX Town in 20xx was drafted in time. Up to September this year 1 day, * * * held special meetings 10 times, formed 24 teams, with team members 160 people, and participated in 580 training sessions on family doctor contract service. On August 29th, 20xx, relevant leaders of District Health Bureau and District CDC were invited to attend and held the "xx Town Family Doctor Service Kick-off Meeting" in Gaodong Village. A number of working meetings were held, including "XX Town Family Doctor Contract Service Work Deployment Meeting", "XX Town Family Doctor Contract Service Work Promotion Meeting", "XX Town Family Doctor Contract Service Work Training Meeting" and "XX Town Family Doctor Contract Service Health Assessment Work Training Meeting". The meeting arranged, promoted and fully discussed the service content, personnel composition, funding guarantee, work continuity and other contents of family doctor service, unified ideas, improved understanding, and laid an organizational foundation for the steady promotion of family doctor service.
(2), extensive publicity, in-depth mobilization
In order to ensure that the contract service of family doctors is deeply rooted in people's hearts, according to the spirit of the document "Publicity Month of Family Doctors in xx District" (No.Li Wei [20xx] 1 12), our town has formulated the Publicity Month of Family Doctors in XX Town, and actively carried out the publicity month of family doctors with the theme of "Let families have doctors and let doctors enter the family". More than 20,000 copies of A Letter to Community Residents, 6,542 copies of Family Doctor Manual15,000 copies of Family Doctor Service Agreement were distributed to residents through various activities, such as going to the countryside for free consultation, health consultation, knowledge lectures, and door-to-door rounds. At the same time, our town also printed 25 editions of publicity column and 30 posters with the theme of promoting the service concept, service content and service form of family doctors, and rented 30 tricycles and pasted them on the left and right sides of the car body, which were publicized through street and village main road demonstrations, effectively creating a well-known publicity atmosphere and laying a public opinion foundation for the smooth promotion of family doctor services.
(3), do a good job in the pilot, and gradually advance.
In the signing service of family doctors in Gaodong Village and Tingjiang Village of XX Town, the services such as chronic disease management, maternal health care management, rehabilitation of the disabled, infant health care, etc. (home visits, home visits, home care) were focused, and the number of people who served and needed were grasped, which laid an information foundation for the town to solidly promote family doctor services.
(D), clear principles, hierarchical management
1, fragmentation service, clear responsibility
According to the distribution characteristics of population and village clinics in XX town, taking 24 village clinics in the jurisdiction as the carrier, the administrative area of XX is "gridded" and assigned to the corresponding village clinics to ensure that the community health service system can cover all residents in XX town. Town health centers and village health centers have formed a "family doctor contract service team" with "general practitioners, community nurses, medical staff and rural doctors" as the core, providing family doctor service. Clarify the distribution of the villages under its jurisdiction, and set up a "family doctor-style contract service team" publicity board in each village department to publicize the team service personnel, service scope, service time, service content, contact information and other information.
2, grading service, clear objectives.
The public health service team divides residents into three levels according to their actual needs for health services and their acceptance of family doctor services. The first level is residents who are temporarily unwilling to receive family doctor services; Second-class residents are only willing to accept family doctor-style services when needed; The third level is residents who are willing to receive family doctor services. Provide different health management services according to different levels of residents.
At the first level, focus on observation, strengthen publicity, and conduct regular and irregular telephone follow-up to understand the changes in their service needs.
The second level focuses on publicity, promoting health management services, and issuing contact cards to family doctors so that they can contact team members at any time when needed.
The third level, based on active service, provides targeted family doctor-style contract services for different categories of special people according to health status and health needs.
3, classified services, clear standards
Third-level residents who are willing to receive family doctor services are divided into four categories according to their health status and health needs: the first category is healthy ordinary people, the second category is people who need attention, the third category is people with chronic diseases, and the fourth category is patients with high-risk or serious complications, disabled people and special patients. According to the categories of residents, the service content and standards are defined, and targeted contract services are provided to ensure service quality and sustainability.
The first group of healthy people aims to promote health.
1. Provide health assessment and planning. According to the information of health records, the health status of residents is evaluated once a year, and the health planning and objectives of residents for the next year are formulated according to the evaluation results.
2. Provide healthy "peer-to-peer" management services. Distribute sanitary materials to contracted residents in time; Timely notification of health education and health promotion activities; Timely notification of seasonal and sudden public health incidents.
3. Hold a symposium of contracted residents' representatives every six months to find out the health risk factors and formulate intervention plans.
4. Provide 24-hour telephone health consultation service.
The second category of people who need attention, such as pregnant women, infants and sub-healthy people. To prevent diseases and promote health as the goal.
1. Provide pregnant women with pregnancy guidance services.
2. Conduct 3 home visits and physical examinations for contracted parturients and newborns.
3, the implementation of stable blood pressure, weight control and other health projects, regular health education and health intervention.
The third kind of chronic diseases, such as hypertension, coronary heart disease, diabetes, etc. Improve the control rate of chronic diseases.
1. Establish and improve family and personal health records, and update them in time during the service period.
2. Provide referral appointment service.
3. Give the contracted residents 1 time/month diet guidance, exercise guidance, medication guidance and disease rehabilitation consultation.
4. Use health lectures for health intervention.
5. Provide psychological counseling, psychological counseling and TCM mental health services.
6, targeted to carry out Chinese medicine health care, health care guidance services.
The fourth category is patients with serious complications, disabled people, special patients and empty nesters. , aimed at alleviating pain and facilitating medical treatment. On the basis of providing services for patients with chronic diseases of category III, the following services are provided:
1, case management of health records.
2. Conduct regular home visits to people who really need them, provide free physical examinations and provide health management services.
3. Provide expert appointment consultation service.
4, to carry out rehabilitation training guidance, improve the quality of life of the disabled, so that they can return to society as soon as possible.
(5) Give priority to signing contracts and provide effective services.
Based on the classification and health demand survey of residents in Gaodong Village and Tingjiang Village, priority should be given to signing family doctor service agreements with key people who are willing to receive family doctor services, such as chronic patients, empty nesters, disabled people, women and children, and providing targeted services such as establishing health files, telephone consultation, home visits and health education according to the contents of the agreements. At present, more than 7,400 households have signed contracts, with 36,522 people signing contracts, accounting for 34.7% of the total service population, among which 1 1936 people, accounting for 32.68% of the contracted population.
Second, the initial results achieved
(1) Limited human resources have achieved the maximum scope of community health services at this stage and improved the accessibility of medical and health services.
All the health technicians in XX Town Health Center participated in the contracted service of family doctors, and * * * set up 24 family doctor service teams, equipped with 27 community health telephones, covering the residents under the jurisdiction of 24 village committees. The family doctor service mode has realized the full coverage of the existing medical staff to the health management of community residents, and provided services to residents from the waiting village, which effectively strengthened the rural health management ability.
(2) It ensures the gradual realization of "six in one" functions such as health education, and improves the level of residents' health protection.
The awareness rate of medical and health services and health knowledge of residents in the area has been improved, health education, preventive health care, rehabilitation and other services have been implemented, and residents' health awareness has been continuously enhanced. 20xx1~ June, the town's family doctor service team received 2 1594 person-times, made 2 16 person-times, signed 5,847 person-times for basic medical care, made health assessment14,467 person-times and signed 7,400 families.
(3) Initially, the health care model has changed from "treatment-oriented" to "prevention-oriented".
Through health education lectures and regular visits, we can know the health problems and health needs of residents in time, implement targeted health interventions for different groups of people, and promote the improvement of residents' health level and quality of life.
(four), the health needs of key groups are basically met, fully reflecting the public welfare.
According to the health status and needs of residents in the jurisdiction, the "classification and grading" management will give priority to the vulnerable groups, patients with chronic diseases and other key groups in the town to receive family doctor-style services with basic medical care and health guidance as the main content, which will alleviate the problem of "difficult and expensive medical treatment" for the disadvantaged groups to some extent and promote the harmony and stability of XX Town.
Third, the next work plan
(A) summing up experience and promoting services
According to the deployment of XX District Health Bureau, our hospital will timely summarize the practice and initial results of carrying out the pilot family doctor service, especially the residents' satisfaction with the family doctor service. At the same time, according to the workflow of determining the target population and signing the service agreement, the family doctor service will be gradually promoted to the residents of the whole town.
(2) Deepen the connotation and improve the service.
According to the residents' growing demand for health services, we will continuously deepen the connotation of family doctor services, adjust the contents of contracted services in a timely manner, and gradually bring medical care, nursing, health education, medication guidance, rehabilitation training and psychological counseling into the scope of family doctor services to effectively meet the residents' health needs.
(3) strengthen the assessment and continue to serve.
In 20xx, the development of family doctor service was included in the performance evaluation of town public health service. Through half-year assessment, annual assessment and irregular supervision and inspection, all the work contents of family doctor service will be promoted in all villages to ensure the continuous promotion and healthy development of family doctor service.
Summary of contracted service for family doctors In the second part, according to the requirements of Wanrong County Health Bureau's Contract Service Scheme for Township Doctors and Village Residents in Grassroots Health Service Institutions, as well as the instructions of the county health bureau's work arrangements and related meetings, combined with the reality of my hometown, we should give full play to the role of village clinics, innovate the service model for rural doctors, and take the contracted service for rural doctors as an important measure to implement the national basic public health service project. Under the guidance of family service doctors, the public health service team carries out the service model of "dicing contract, teamwork and responsibility to people" in rural areas for life. The specific situation of migrant workers in China is summarized as follows:
I. Basic information
There are 2/kloc-0 administrative villages, 2/kloc-0 township hospitals and 2/kloc-0 standard hospitals in my township, covering 6480 contracted families and involving 26990 people.
Second, the work progress
At the beginning of May, 20xx, a working group led by health centers was established in our township. Surgeons at home and abroad responded positively, set up a contract team, held a seminar, carefully studied and discussed the basis, system, responsibilities, content, process and requirements of family doctor service, and made clear the job responsibilities and service scope. Team members brainstorm and work out feasible signing methods and steps according to the characteristics of residents in my hometown, so as to complete the task in the shortest time. At the same time, the person in charge of the health center also went deep into the masses, vigorously publicized the necessity of developing family doctor service, explained the relevant matters of signing the contract in detail, answered residents' questions about this work, and let residents fully understand the connotation of family doctor service, which achieved good publicity results. The broad masses of residents have eliminated misunderstandings and supported the signing work in succession.
In mid-May, the signing of family doctors was officially launched in our township, and family doctors will also go deep into their respective communities to sign contracts door to door, so as to overcome various difficulties and strive to complete the signing service of family doctors as soon as possible so that everyone can enjoy basic medical and health services. At the same time, the village health center will continue to strengthen the publicity of family doctor service, further strengthen the construction of service team, enhance the cohesion of service team, win over different groups of people, and carry out various forms of family doctor service projects and activities.
At present, 2 1 health centers in my hometown have all carried out contract service, and * * * has signed a contract for family service for 373 1 household. Our hospital will summarize the initial results of developing family doctor service in time, especially the satisfaction of hometown residents with family doctor contract service, and further improve it.
In order to further promote the basic public health service project of Yingnan Office and effectively change the service mode, according to the implementation plan of family doctor contract service system of primary medical and health institutions in Fuyang City in 20xx, combined with the reality of our town, the progress of the work is summarized as follows: In order to fully meet the needs of community health services, Yingnan Community Health Service Center started the family doctor service. Set up Yingnan Community Health Service Team (National Basic Public Health Service Team; Family and community doctor service team); Family doctor service is centered on family doctors, supported by general practice team service, centered on residents' health and family as a unit. Family doctors sign service agreements with residents to provide basic medical and public health services for contracted families or residents.
Central service team, divided into three groups, each group is composed of doctors, nurses and public health personnel, and provides door-to-door services, basic medical services, outpatient appointment services, residents' first visit signing and two-way referral services in combination with the three-level management responsibility system of basic public health services; Formulate rehabilitation plans for the disabled, and guide and supervise rehabilitation training; Provide on-site health consultation and guidance services for empty nesters and elderly people with mobility difficulties; Family members carry out personalized TCM physique appraisal and personalized TCM health care; Provide family health psychological counseling and health support. Family doctors actively understand the health status of contracted families, make health plans, and implement effective health interventions for key groups such as chronic diseases, the elderly, children and pregnant women.
As of 20xx.xx.xx, the urban communities in Yingnan District have signed up 1 149 households, with a contracted population of 4,454, a key population of 1300, and a total population of116.
Through the introduction and door-to-door signing service, it is found that there are many people going out and there is great mobility. Some villagers' family doctors have poor awareness of contract service, and they have repeatedly publicized and mobilized, so they cannot trust the service model. It is believed that the medical conditions of contracted units are poor, not as good as municipal hospitals, and they cannot be trusted; Individual families think it is best not to sign a contract. They have health problems, so it is convenient to contact 120 at any time. No need for community service.
In the future work, vigorously promote the family doctor service model, build a harmonious doctor-patient relationship, establish a stable health service relationship with residents in the area, and become a caring person for the healthy life of residents in the area! Mainly responsible for the diagnosis and treatment, health examination and health guidance and consulting services of residents within the jurisdiction, conscientiously do a good job in the diagnosis and treatment of common diseases, frequently-occurring diseases, chronic diseases and infectious diseases, and do a good job in first aid and referral outside the hospital; To undertake the health records and medical care work of residents in the jurisdiction; According to the main health problems of residents in the area, formulate and implement service plans; Provide one-to-one service mode; Be the patron saint of the health of residents in the jurisdiction!
Summary of contract services for family doctors 5 1. Attach great importance to it and actively deploy it.
The implementation plan of family doctors' contract service in xx street in 20xx was formulated, and the leading group and the contract service group of family doctors were set up at the same time. The team members were organized to study the spirit of the work plan in time, and the basic principles, service contents, service objects and work continuity of family doctors' service were fully discussed, which unified their thinking and improved their understanding. It laid an organizational foundation for the steady advancement of family doctor services. In order to ensure the popularization of family doctor service, a family doctor service agreement was signed with the villagers.
Second, extensive publicity and in-depth mobilization
In order to ensure the popularization of family doctor service, our center uniformly printed leaflets with the theme of promoting the concept, content and form of family doctor service, which were distributed to village clinics and village committees in this area. At the same time, family doctor contact cards and family doctor service agreements are printed, and publicity banners and billboards are made. It has effectively created a well-known publicity atmosphere and laid a public opinion foundation for the smooth development of family doctor services.
Third, investigate the demand and provide personalized service.
Among the residents who signed up for the service, the medical and health services that residents hope to get were investigated. Including health education and health promotion, chronic disease management, maternal health care management, infant health care and other services, community health service centers are responsible for checking, guiding and assisting in signing family doctors, conducting home visits and health education, and doing a good job in performance services such as health examination, step-by-step referral and health assessment. According to the requirements of the "1+1+"service team, the hospital led by doctors provides technical support and business guidance, assists specialists to carry out remote consultation and health talks, implements relevant measures to refer patients to the blue channel, helps family doctors to carry out some technical services that they cannot afford, and ensures that services are carried out in accordance with the provisions of the agreement. The clarity of the service population and the mastery of the number of people in need have laid an information foundation for the solid promotion of family doctor services.
Four, clear object, on-demand management
Family doctor contract service team is the main provider of contract service. In principle, the family doctor service team consists of family doctors, clinicians or general practitioners in township hospitals, health management personnel (nurses, public health doctors) and doctors selected by leading hospitals of medical institutions, and the team leader is the central doctor. Family doctors are qualified rural doctors in village clinics managed by township integration. The center is the direct person in charge of the management of family doctor's contract service. In order to further clarify the population distribution in the jurisdiction and ensure that the community health service system can cover all residents. Publicity team service personnel, service scope, service time, service content, contact information and other information. Family doctors are contracted to serve all urban and rural residents, giving priority to the elderly over 65 and patients with chronic diseases (hypertension, diabetes, chronic bronchitis, etc.). ), pregnant women, children aged 0-6, poor people, and special family members of family planning. According to the categories of residents, the service content and standards are defined, and targeted contract services are provided to ensure service quality and sustainability.
5. Give priority to signing contracts and provide effective services. Priority will be given to signing family doctor service agreements with key people who are willing to accept family doctor services, such as patients with chronic diseases, empty nesters, women and children, and providing targeted services such as establishing health files, telephone consultation, home visits and health education according to the contents of the agreement.
By the end of 20xx, we will establish and improve the electronic health records of poverty-stricken people and poor family planning assistance objects, realize full coverage of family doctors signing services for poverty-stricken people and poor family planning assistance objects, sign free paid packages for key groups such as the elderly over 65, hypertension and diabetes, and provide effective basic public health services, health management and appointment referral services.
6. Successfully completed the signing and performance of the 20xx family doctor signing service.
In 20xx, I signed a contract with xxxx people, including xxxx people for paid package tasks. My street * * * completed paid package contracts, with more than xxxx people, including xxxx people signing paid packages, and more than xxxx people signing free contracts for family planning assistance and xxxx poor people. At present, 92.36% of the annual family doctor contract has been fulfilled, reaching 90% of the performance requirements required by the District Health Planning Commission.
Seven, shortcomings in the work.
1, the publicity of the contract service is not extensive enough, some remote village groups are not well publicized, and some village cadres do not understand and thoroughly understand the contract service;
2. The signing work was sloppy, and the service package content was not informed at the time of signing, resulting in some personnel not understanding and not cooperating with the performance;
3. The inspection speed of all-in-one machine is slow and lagging behind. Some village clinics have not achieved full coverage of all-in-one inspection, and a few have entered records in the system without all-in-one inspection records. It may be related to the aging, unstable performance, short standby time and inactive work of village doctors.
4. The actual performance time, service manual registration time and service table recording time are inconsistent with the time entered in the system;
5. Some village clinics have chaotic information and ledger management. Because the list of poor people in 20xx has been adjusted many times, some village doctors can't distinguish the latest ledger.
VIII. Work Plan for the Next Year
1, organize health service centers and medical staff, village committee secretaries and health professionals in village clinics to learn the spirit of the work plan, closely focus on the basic principles, service contents, clients and work continuity of family doctor service, unify their thinking, raise their awareness, and lay an organizational foundation for the steady advancement of family doctor service;
2 printed leaflets with the theme of promoting the service concept, service content and service form of family doctors, and distributed them to the neighborhood committees in this area. At the same time, family doctor contact cards and family doctor service agreements are printed. , and produced publicity banners and billboards, effectively creating a well-known publicity atmosphere;
3. Solidly carry out the contract service agreement, invoice, fund arrangement, collection and distribution of family doctors, and steadily promote the performance of 20xx family doctors' contract services such as ward rounds and physical examinations.
Summary of family doctor contract service 20 18 19 May 6th is the 8th World Family Doctor Day. In order to further strengthen the publicity of family doctor contract service, create a good social atmosphere, reasonably guide residents' expectations, and improve residents' enthusiasm for contract signing, according to the Notice of Lingshi County Health and Family Planning Bureau on Launching 20xx Family Doctor Contract Service Theme Publicity Month (Lingweifa [20xx] No.73), on the morning of May 24th, xx Town Health Center of Lingshi County launched a publicity campaign with the theme of "Family doctor contract service" in xx Town Square.
The leaders of our hospital attached great importance to this publicity and personally led the team. *** 12 professionals participated in this activity.
The theme banner-"Family doctor: I promise to serve" was hung at the event site, and an information desk was set up. Family doctors enthusiastically explain the relevant knowledge to the people who come to consult, and take blood pressure and blood sugar for the people free of charge.
The purpose and significance of the activity were introduced to the residents, and publicity materials were distributed, so that more residents could understand the contracting service and be willing to sign contracts with family doctors.
The contract service of family doctors is mainly general practitioners, providing personalized medical care services for residents. They will regularly update residents' health records and make suggestions on health maintenance. The elderly and disabled people with mobility difficulties can enjoy the on-site service of family doctors, who will follow up the health status of residents every once in a while to facilitate residents to enjoy convenient medical services, thus improving their health level and quality of life.
The team of family doctors took advantage of the publicity opportunity to explain the knowledge about family doctors to residents in the hospital of XX village clinic in the form of lectures. Zhang Zhiyuan Xibao personally gave lectures to residents and patiently and meticulously guided them to a correct lifestyle. Family doctors teach residents how to measure blood pressure and monitor body mass index correctly, and consult through communication and interaction. For the disabled and the elderly in the area under the jurisdiction of the family doctor team, the hospital leaders personally led the team to provide home service, signing contracts, measuring blood pressure, blood sugar and health guidance.
In this activity, we hung a banner, made two exhibition boards, held a consultation, held a lecture, received more than 30 consultations, followed up at home for 20 times, signed contracts on site for 20 times, distributed 65,438+0,000 leaflets on family doctor contracting services, 200 public health service manuals, 200 publicity bags and 65,438 publicity aprons.
Through this activity, the distance between residents and family doctors has been further narrowed, community residents' understanding of family doctor contract service has been improved, and the healthy development of family doctor contract service has been promoted.
XX Town Health Center regards this work as an important task, so that the policy of benefiting the people can really enter every household, and the people with mobility difficulties can really feel the intimacy and care brought by convenient medical services. Through the publicity campaign of "family doctor contract service", more people have a deeper understanding and understanding of "family doctor contract service", which has better mobilized the enthusiasm of the people to cooperate with family doctor contract service and played a good role in promoting the goal of everyone enjoying basic medical and health services.