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          主辦單位:北京市社區衛生服務管理中心

          便民服務

          服務中心查詢

          家庭醫生簽約服務

          82982.jpg

          為貫徹落實國務院新“醫改”精神,緊密圍繞“保基本、強基層、建機制”的工作要求,在北京市委、市政府的領導下,首都社區衛生服務充分將政府“以人為本”的執政理念以及履行民生管理責任緊密聯系,創新性的提出并全面推進家庭醫生簽約服務工作。

          什么是家庭醫生簽約服務?

          家庭醫生簽約服務是北京市衛生局按照市政府提出的“普及健康知識、參與健康行動、提供健康保障、延長健康壽命”的目標,借鑒先進的家庭醫生服務理念,開展以社區衛生服務團隊為核心,在充分告知、自愿簽約、自由選擇、規范服務的原則下與服務家庭簽訂協議,為居民提供主動、連續、綜合的健康責任制管理服務。

          家庭醫生簽約服務如何開展?

          家庭醫生簽約服務主要依靠社區衛生服務團隊來開展,一只完整的社區衛生服務團隊由全科醫師、社區護士、預防保健人員組成。居民只需在居住地的社區衛生服務機構自由選擇服務團隊,無需繳納任何費用,簡單簽署一份《家庭醫生簽約服務協議書》,便可免費享受健康“點對點”服務。

          家庭醫生簽約服務內容

          北京市家庭醫生簽約服務模式的服務內涵宗旨是:將家庭醫生簽約服務模式作為社區衛生服務運行和開展各項業務的核心方式和思路,其貫穿于整個社區衛生服務體系中,它涉及和涵蓋了社區衛生服務體系各個層面,融合于各項基本醫療和公共衛生服務中。

          1.基本醫療服務

          家庭醫生簽約服務模式在基本醫療中,主要是建立起特色的家庭醫生簽約服務診療流程,推行預約就診制度,體現健康管理。與傳統的和大醫院的診療流程比較,家庭醫生簽約服務診療流程有三個主要特點:一是患者不再被隨機分配就診,而是直接預約、分診至其簽約醫生處進行候診;二是患者不再是單純診病,而是接受醫護團隊的健康管理,必須保證與居民充足交流時間,當次診療結束時,要視情況與就診居民預約下一次復診時間,或提供轉診服務;三是簽約患者享有優先就診等簽約便利。

          1.1就診預約。簽約醫生與居民實行預約就診。預約方式可以是簽約醫生在接診時或通過電話、短信等方式與居民預約就診時間,也可以是居民通過社區衛生服務中心預約電話或窗口與簽約醫生預約。目的是減少醫患雙方的接診和就診的盲目性,減少居民候診時間,增強社區衛生人員工作的計劃性。

          1.2定向分診。就診居民按照預約時間來社區衛生服務機構時,機構要直接將預約就診居民分診至其簽約醫生處進行候診。目的是建立和密切醫患之間固定的服務關系,便于為居民提供連續的社區衛生服務。

          1.3診前服務。充分利用居民候診時間,引導居民進行健康狀況自助監測或進行相關診療基本信息采集。為居民提供健康管理服務,開展家庭醫生簽約服務中的"健康狀況早了解"、"健康信息早知道"、"分類服務我主動"等適宜服務內容。目的是體現社區衛生服務的健康管理職責而非僅診療行為,提高診療效率,提升健康管理效果。

          1.4診療服務。

          (1)提供診療服務時,做到診室內醫生和就診居民"一對一"交流。目的是為醫生和就診居民營造舒心的診療氛圍,保護患者隱私。

          (2)開展門診接診服務時,要根據就診居民實際情況,按照技術操作規范提供診療服務,并保證時間能與就診居民進行充分交流。目的是保證診療質量,和諧醫患關系。

          (3)當次診療結束時,要視情況與就診居民預約下一次復診時間,或提供轉診服務,同時及時完善健康檔案信息。目的是讓就診居民感受到社區衛生人員對其健康的負責態度,從而使居民對社區衛生服務感到放心,增強居民對社區衛生服務的信任感。

          2.基本公共衛生服務主要按照國家基本公共衛生服務規范及相關專業衛生部門要求執行各項公共衛生服務。

          3.個性化健康管理服務簽約居民可享受到以健康管理為宗旨、以主動服務為特色的多項個性化的服務和優惠措施:

          (1)健康需求先分類-通過社區診斷,了解轄區居民情況,根據居民的實際健康需求及其主要健康問題,對人群進行分類,做到"底數清"。

          (2)健康狀況早了解-及時為簽約居民體檢和建立/完善健康檔案并做好健康評價,量體制訂1份目標明確、操作性強的年度健康管理方案并實施。

          (3)健康信息早知道-利用多種信息聯通方式,根據簽約家庭健康狀況,及時主動將健康活動信息和季節性、突發性公共衛生事件信息告知簽約家庭,為居民提供健康咨詢服務。

          (4)分類服務我主動-按照分類管理原則,對于健康普通人群,以維護健康為目標;對于有健康危險因素人群,以預防疾病促進健康為目標;對于慢性病患者,以提高慢性病控制率為目標;對于老年人、婦幼人群等特殊人群,做好個性化管理;對于功能社區人員,建立功能社區人員健康檔案,推廣功能社區服務特色。

          (5)健康技能我指導-針對簽約居民健康需求,通過教學培訓或操作指導,使居民掌握一項健康自我管理的必備技術,如正確測量血壓/血糖、護理、運動鍛煉等技能。在醫務人員指導下,能自主的正確使用健康自測相關儀器。

          (6)貼心服務我上門-對空巢、行動不便并有需求的老年人提供上門健康咨詢和指導服務。

          (7)中醫養生保健服務-為適宜人群提供中醫體質辨識、中醫藥膳、中醫四季養生保健、中醫慢性病管理、中醫康復、中醫代茶飲、中醫適宜技術服務。

          以上服務為基本服務項目,不收取費用。各區縣、各機構可根據自身情況增加、細化服務項目,如涉及收費項目,則按照有關文件標準執行。

          北京社區衛生服務微信公眾帳號

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