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目的:研究社区对慢性病的干预措施,提升社区对慢性病的规范化预防水平。方法:我社区根据过去的干预路径经验,对慢性病社区干预的长度、时间、动态监测、周期等指标进行筛选,改变原有的路径书版本设计,提升社区干预路径水平。结果:医生对慢性病的每一步干预措施都有章可循,患者版的路径书让患者全年度都有计划的进行干预,能够积极的配合各项干预措施。结论:慢性病社区干预路径的创建和研究能够发挥引领航作用。
Objectives: To study community-based interventions on chronic diseases and to promote community-level prevention and control of chronic diseases. Methods: Based on the past experience of intervention pathways, my community screened the length, time, dynamic monitoring and period of community interventions for chronic diseases to change the version of the original version of path books and improve the level of community intervention pathways. Results: Physicians’ interventions for each step of chronic disease were followed. The patient version of the pathbook allowed patients to have planned interventions throughout the year and could actively cooperate with various interventions. Conclusion: The establishment and study of community intervention pathways for chronic diseases can lead the navigation.