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The construction of county medical service community (medical community) is an important measure for building a hierarchical and integrated medical and health service system. The article takes Yinzhou District of Ningbo city as an example to elaborate the strengths and weaknesses of the internal environment and the opportunities and challenges of the external conditions using SWOT analysis in the construction of county medical community, also put forward corresponding countermeasures and suggestions to provide reference for the further improvement.
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Objective:To investigate the disease spectrum referred from the community health service centers to the district tertiary hospital in the region.Method:The data of the referred patients from the community health service centers to Shanghai Yangpu District Hospital-a tertiary hospital in the region from January 2016 to December 2019 were collected. The composition and characteristics of the disease spectrum of the referred patients were analyzed.Results:The number of patient visits to the community health service centers in the region was increased from 4 684 938 in 2016 to 4 776 921 in 2019. The number of patient referral from the community centers to Yangpu Hospital was increased from 3 125 in 2016 to 6 853 in 2019. There were total 18 308 patients referred in 4 years, including 8 012 males (43.8%) and 10 296 females (56.2%). The age range of referred patients was from 1 to 99 years, including 53 referred patients aged ≤ 18 (0.3%), 927 aged 19-39 (5.1%), 2 831 aged 40-59 (15.5%), 4 424 aged 60-79 (62.2%) and 1 209 aged ≥ 80 (17%). The top five systems of diseases, which accounted more than 60% of total diseases, were circulatory system, endocrine nutrition and metabolic system, urogenital system, eye and appendage, and digestive system. Compared with male patients, more female patients with urogenital diseases were referred.Conclusion:The referral rate of community health service centers were increased from 2016 to 2019. The referred patients cover all age groups, more frequently in age group 60-79. The diseases of referred patients cover all system, and are different between males and females.
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In order to further promote hierarchical medical system and enhance the capacity of primary healthcare services, China began to build compact county medical community. At present, the development of China′s compact county community still exists such problems as the construction of service system, the basic institutional mechanism, the quality of supply capacity and the core guarantee mechanism. In order to solve the existing problems, the authors took Shaxian District of Sanming City, Fujian Province, Dancheng County of Zhoukou City, Henan Province, and Yangqu County, Taiyuan City, Shanxi Province as examples to summarize the experience of the advanced pilot areas of the policy. In the future, the construction of compact county community in China should be based on the construction of " single-core multi-layer" system, starting from the five levels of collaborative management, practical operation, system construction, basic guarantee and multi-party supervision, to comprehensively enhance the healthcare services, and finally achieve the goal of the strategy of hierarchical medical and Healthy China.
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Objective:To analyze the current status of referral of stroke inpatients and explore the characteristics of the referral network in Changsha, for the reference to improve and promote the hierarchical medical system of stroke.Methods:Data of the inpatient medical record of stroke patients and the annual reports of medical institutions in Changsha in 2018 were collected from the health statistics network direct reporting system of Health Commission of Hunan province, for analysis of the referrals of inpatients in different medical institutions. Social network analysis was adopted to analyze the density, centrality and K-core of the referral network of stroke inpatients.Results:A total of 82 medical institutions for stroke inpatients were included with 2 859 referrals of patients. Most of the referrals were made between tertiary hospitals(1 515), especially within hospitals of a stroke alliance(1 123). The density of referral network was 0.613.Tertiary hospitals were in the center of the network, the entry points of secondary hospitals were in the center of the network and primary medical institutions were located at peripheral positions. Most of the tertiary hospitals in the 15-core(14, 72.68%), 12 of them were the units of Hunan Stroke Alliance.Conclusions:Tertiary hospitals played an important role in the region, secondary hospitals were able to receive patients referred by tertiary hospitals, but few patients were transferred to primary care institutions; The primary medical institutions failed to play due roles in the referral network. The establishment of stroke alliances could promote the cooperation of hospitals in the alliance, but the division of labor and cooperation among different levels of medical institutions in the region needed to be further optimized.
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Objective:To explore the changes of disease structure in a tertiary general hospital during the COVID-19 pandemic.Methods:A database of 783 diagnosis-related groups(DRG) patients in a tertiary general hospital from 2017 to 2020 was used. The rank sum test was used to compare the number of patients among different years, and the Chi-square test was used to compare the composition of patients among different years. With the patient composition ratio as the main index, the thermal cluster analysis was used to analyze the changes of disease structure during the COVID-19 pandemic, from the perspectives of major diagnostic categories(MDC) and the key DRG(the number of patients in any year more than 2 000)respectively. All analyses were performed in R software, with P<0.05 indicating significance. Results:There were significant differences in the number and composition of patients in MDC groups and key DRG groups among different years( P<0.05). The results of thermal clustering analysis showed that the MDC composition of patients in 2020 was significantly different from those in 2017 to 2019; the 26 MDC groups were classified into four main categories. The results of thermal clustering analysis also showed that the DRG composition of patients in 2020 were significantly different from those in 2017 to 2019; The RU14 group and the other 19 key DRG groups were classified into different groups; and the other 19 key DRG groups except RU14 were classified into five main categories. Conclusions:The disease structure of tertiary general hospitals has changed significantly during the COVID-19 pandemic.
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Critical care medicine has developed rapidly and has become an indispensable comprehensive subject in clinical medicine at home and abroad.In recent years,the government has vigorously implemented the "Healthy China" strategy and strived to achieve a higher level of national health.The Henan Provincial People's Hospital has set up a network of interconnected "Wisdom · Critical Care Medicine Specialist League" to meet the major strategic needs of the country,and to play a role in attracting large hospitals to promote the sinking of quality medical resources and the improvement of grassroots service capabilities.Complementary advantages and resource sharing are conducive to achieve win-win cooperation and coordinated development between the third-grade class-A hospital and grassroots hospitals.
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With the progress of the hierarchical medical system, the top-level design for building medical alliances is exhibiting a clearer picture. The Chinese government sets about trying to build a grid-based medical system layout, covering from national, provincial, municipal, county, township, all the way to village level. Based on the analysis of regional grid-based medical systems in the United States, Switzerland, Singapore and Canada, the authors reviewed the development of grid-based health service system in China, and found out key roadblocks for grid-based medical alliances. These problems include the organizational structure, service content, management mechanism, payment system and other aspects, and corresponding countermeasures and suggestions were proposed in the end.
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Active exploration for building a model of medical alliances fitting local needs, proves imperative for the functional positioning of medical institutions, promoting inter-institutional cooperation and enhancing the capacity of primary medical services. The authors described experiences and insights of the No.1 Affiliated Hospital and the People′s government of Quangang District in their partnership, and building a brand new model of medical alliance between a hospital and a local government. Also presented are characteristics of such a model, and analysis of operational data in benefiting the people. They held that such a partnership is a worthy attempt in the healthcare reform, by means of building medical alliances between local government and provincial hospitals. Such a practice can provide valuable references for promoting government-hospital synergy, elevating primary healthcare capacity and advancing the hierarchical medical system.
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Objective To analyze the dilemmas of our hierarchical medical system, in order to seek a viable path for effective implementation.Methods Based on the Meter-horn model, six related factors were used, including policy standards and goals, policy resources, implementation methods, characteristics of the actuator, value orientation of the executive and the system environment, to analyze the dilemmas of the implementation of hierarchical medical system.Results This policy had not achieved the expected effect in the implementation process, which deviated from the original intention of policy designers to some extent. There exist the following setbacks for the roadblocks. For example, policy standard was ambiguous, the policy resources were insufficient, the execution method was not proper, the implementation mechanism was"criticized" , the implementation personnel value orientation was biased and the complex system environment.Conclusions All the factors involved in the implementation of the hierarchical medical policy affect each other.In this consideration, medical institutions at all levels and the relevant departments should coordinate and deal with the relationship between these six related factors, and timely take effective measures to amend and improve the policy, so as to ensure the orderly progress and long-term implementation of the hierarchical medical system.
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Based on a sufficient analysis of the theoretical framework of " transformation learning collaboration" ( TLC ) and " people-centered and integrated health care " ( PCIC ) mode, this article introduced the main practices and achievements of " Hangzhou characteristics" countywide medical alliances, centering on TLC mode.Hangzhou takes the countywide medical alliance construction as a pilot, refers to the TLC model, and takes growth-oriented collaboration as the guidance, to promote responsibility sharing, benefit sharing, service integration and management collaboration.Guided by the PCIC model proposed by the World Health Organization, the city has established an integrated service model of hierarchical medical system-prevention-rehabilitation-aging care.The countywide medical alliance system framework features " 5 fields, unified leadership, unified culture, 6 supports, 3 tasks and TLC teams " , which may provide references for the coordinated and integrated development of such alliances.
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Digital healthcare empowers optimization of medical services.This article introduced the practices and achievements of Hangzhou in the following aspects: the construction of a hierarchical medical system guided by " people-oriented integrated service" ; development of the five digital platforms, namely regional health information platform, integrated medical care platform, remote consultation platform, intelligent supervision platform and doctor-patient remote interaction platform; development of " Smart Medicine" to promote institutional cooperation, service integration, management coordination, quality improvement and doctor-patient interaction.The paper also analyzed the supporting role of digital healthcare construction in promoting the hierarchical medical system, and put forward corresponding countermeasures and suggestions.
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Higher service efficiency and better medical experience are main goals of the healthcare system reform.The article explained the logical framework, main actions, initial results of the " one visit for all" reform, which aims at promoting the efficiency of medical services and management in Hangzhou.Policy suggestions are raised, namely involving more people into the governance mechanism, collaboratively optimizing the working process of medical staff, improving the information security mechanism, and perfecting the effectiveness evaluation system.These measures are designed to accelerate the construction of modern hospital management system, and to build a scientific and orderly hierarchical medical system.
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" Day surgery hospital-community joint follow-up model " results newly from the deepening implementation of the hierarchical medical system policy. It is designed to follow up the patients discharged from hospital but not fully recovered in time to ensure the prevention of adverse events after surgery. It can also improve the quality and efficiency of follow-up, and ensure the safety and integrity of the whole day operation management. In this context, through a comparative study of 720 patients discharged from daytime surgery in the region, patients in the combined follow-up group were followed up by telephone on the 3rd day after the operation by nurses from the day surgery ward. On the 10th and 20th days after the operation, the family doctor from the community health service center will visit the patient at home and follow up the patient by telephone. One month later, the patient returned to the hospital for follow-up consultation. Follow-up results show day surgery hospital-community joint mode as a helpful aid in keeping track of the patients postoperative rehabilitation, reducing complications and handling in time, while improving the ambulatory surgery perioperative safety.
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Objective To analyze the patient information and hospitalization of non-local patients whose medical expenses will be directly settled with their local medical insurance network by a tertiary hospital in Tianjin, and to suggest on further development of direct settlement of medical insurance networking for non-local patients in Tianjin. Methods A retrospective analysis was made on the data of 1 068 non-local patients whose medical expenses were directly settled via medical insurance network from September 2017 to September 2018. Results The majority of non-local patients came from Hebei province, mostly over 51 years old; these inpatient focus on the renown key disciplines such as urology and cardiology;about a half of them were surgical patients; the proportion of patients with chronic diseases was high. These non-local patients in Tianjin feature higher age, more hospitalizations, lower self-paid expenses and lower overall hospitalization costs. Conclusions We should strictly control the referral system of non-local patients, strengthen medical support to areas of poor medical conditions, strengthen the hierarchical medical system; enhance the publicity of non-local patient online settlement and policy awareness, and simplify the filing process. It is also important to enhance network construction and data stability.
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Development of medical alliances is an important step and institutional innovation to deepen the healthcare reform.The authors analyzed the practice and experience in Fujian Provincial Hospital in this regard, and discussed the confusion and difficulties faced in the process.On such basis, they raised such proposals as transforming conception of the people, forming a multi-departmental coordination mechanism and policy superposition effect, building a sound medical alliance assessment system, and clarifying information construction standards, hence developing a new era of hierarchical medical system by means of developing medical alliances.
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Objective To analyze the problems existing in the implementation of the hierarchical medical system in China under the new situation .Methods The Smith policy implementation process model was used as an analytic framework.By means of literature analysis ,stakeholder analysis and PEST analysis ,the analysis was conducted in terms of such elements as the Smith policy implementation process model ,namely ,the idealized policy ,the implementing organization ,the target group and the environmental factors ,as well as its mechanism of action .Results The literature review found that the main obstacle that hinders the smooth implementation of the hierarchical medical system was the lagging of relevant supporting measures ,which accounted for 16.6％ (161)of the problems.In addition ,defects in policy design(the lack of division and cooperation mechanism etc .)and constraints in existing institutional mechanism (separation of revenue and expenditure ,unclear orientation ,etc .) were suggested to accelerate the introduction of supporting policies ,respectively accounting for 6.0％(58) and 9.3％ (90 ) of the results .Conclusions In the process of policy implementation ,the relationship between the four elements of the ideal policy outcomes ,the implementing organization ,the target group and the environmental factors needs to be coordinated to ensure the effective implementation of the hierarchical medical system .
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Described in the paper is the practice of Chengdu in its pilot of medical alliances in 2015 ,which effectively elevated the medical capacity and quality of care of medical institutions within Pujiang county. Such measures as enhanced management and mechanism ,clarified government responsibility ,standardized medical service quality ,and enhanced coordination within the healthcare system are proposed to enhance the medical alliances and the hierarchical medical system .
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A two-way referral system for eye diseases management was developed between the Weifang community health service centers and Shanghai eye hospital in May 2014.With the “peer-to-peer” two-way referral model, the physicians in community health service center and ophthalmologists in eye hospital were directly responsible for screening , diagnosis and treatment of patients.The specialists of eye hospital also regularly provided clinic service in the center for longitudinal management of the patients .The “peer-to-peer” two-way referral model played a positive role in enhancing the cooperation between community health service center and superior hospital , upgrading skills of general practitioners, and improving the residents′satisfaction.
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Objective:It discussed the decision-making mechanism of medical market on supply side and how the hierarchical medical system help inhibiting the excessive medical behavior.Methods:Establishing medical behavior choice model based on the perspective of supply side and hierachy diagnosis Results and Conclusion:In the case of incomplete information and rigid demand hypothesis,the patient would accept all the supplies doctor offered and there was structural unbalance in both general medical market and advanced medical market which meant the excessive medical treatment existed.Under the hierarchical medical system,distinguishing by primary medical institution,both generalmedical market and advanced medical market reached equilibrium which improved the social resource allocation efficiency and the patients' welfare at the same time.
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Objective:To undemtand the direction and synergic relationship of the reform policy of Hierarchical Medical Treatment from perspective of urban public hospital of Guangdong.Methods:Policy analysis and the rainbow model of integrated care.Results:58 pohcy documents were included in analysis.A policy package was established based on the rainbow model of integrated care.The direction of the reform policy was clear but the synergic relationship among some policy measures was still not precise.Conclusion:The policy package was on conceptual phase.It was necessary to supplement some reform policies and measures to build synergic relationship productively.