I. The basic situation of the community health of Balsam Road
Balsam Road community population of 25,113 people, with a total of 6,415 households, including the floating population. The key age groups counted 1,153 children aged 0-7 years old and 792 elderly people aged 60 years old and above. The occupation of the community population is mostly industrial workers and retirees. Community chronic disease statistics, 512 people with hypertension, 158 people with diabetes, 20 people with chronic bronchitis, 28 people with heart disease, 10 people with tumors, 10 people with disabilities.
Community diseases are prevalent, the community elderly to hypertension, diabetes, osteoarthritis and other chronic diseases. Chronic disease residents and patients generally have a lack of awareness of prevention and treatment. Residents of chronic disease risk factors are: smoking, high salt, high fat, alcoholism, obesity, lack of physical activity. The community's resident population of the elderly reached more than 8%, the population is aging seriously, so community health should try to the elderly.
The cultural structure of the community's population over 15 years old: 70% middle school students, 19.5% high school, 10% university, and 0.5% illiterate. The per capita monthly household income is more than 1100 yuan, and the per capita monthly expenditure is about 550 yuan. Medical insurance status of community residents: 75% self-funded, 25% urban medical insurance. The community's permanent residents over the age of 15 engage in physical exercise such as walking and dancing, accounting for 30% of the total residents.
Second, the guiding ideology
The party's "17" spirit as a guide to build a new urban health service system as the content of the community health service system and the connotation of the construction project as the focus to improve the service function and improve the service capacity as the core, so that the work of the Xiangzhang Road community health services have been significantly improved. Obviously improve.
Third, the principle
One is to adhere to the government-led, hierarchical responsibility, and strengthen the government's responsibility for community health services
Two is to adhere to the transformation of functions, improve the connotation of the construction of medical innovation and operational mechanisms to improve the effectiveness of the work of the community health services, and steadily promote the work of community health services, and strive to improve the quality and level of community health services
Three is to adhere to the prevention, prevention and treatment, Chinese and Western medicine, and the importance of community health services. Combination of prevention and treatment, Chinese and Western medicine, health promotion, and strive to meet the growing health needs of residents
Four adhere to the principle of government guidance, departmental collaboration, a variety of ownership components of the medical institutions involved in community health services.
Fifth, adhere to the regional health planning as a guide to make full use of existing health resources as the main body, the principle of government investment and resource adjustment.
Six adhere to the principle of community-oriented people and patient-centered
Fourth, the goal
1, to improve the health of the residents of the Xiangzhang Road community, extend life expectancy, and improve their quality of life
2, the implementation of the full responsibility for all services, full-time service, the whole process of care, the "triple" services To provide residents with all-round health services and make the Xiangzhang Road community one of the healthy communities in Changsha City
3. To promote the construction of spiritual civilization in the community of Xiangzhang Road
4. To realize the system of efficient, low-consumption, high-quality, inexpensive, and convenient community health services, so as to realize the principle of "major illnesses go to the hospital, minor illnesses go to the community"
5. To strengthen the construction of human resources and the construction of community health services. Talent team building, community health service organizations to improve the overall quality of the team, the concept of change in place
6, give full play to the "integration of prevention, health care, medical care, rehabilitation, health education and family planning and other services as a whole, effective, affordable, convenient, comprehensive, continuous grass-roots level of health services. "Six-in-one" function, strengthen the community health connotation and capacity building
7, the establishment of community residents "green life channel", benefiting poor residents.
8. . Continue to strengthen the publicity of community health services, additional services, the work of community health services to really put into practice, so that the 2014 Balsam Road community residents of community health services, service utilization and service satisfaction rate of 85%, 75% and 80% or more, respectively.
V. Main Work
1. Improve the connotation of community health service institutions and high-quality health records of residents, equipped with the necessary basic equipment to enrich the "six-in-one" service function, increase the training of talents, strengthen professional and technical, community appropriate technology and management skills training, actively promote Chinese medicine services, chronic disease prevention and treatment, rehabilitation of disabled persons, health education and other promotional activities, and continuously improve the community health services. Education and other promotional activities, and constantly improve the quality of community health services, so that community residents know more than 85%, enjoy services in more than 75%, and gradually improve the content of the 2009 residents' health records, so that the Xiangzhang Road community new health records in 2014 to reach more than 90%.
2, . Change the concept, update the service mode, take the initiative to carry out door-to-door service, extended service, continuous service and hospice service, the implementation of community health service preferential policies, specifically the implementation of the "five free and two lowered" (free of registration fee, free of the first consultation fee, free of the clinic fee, free of injection fee, free of the health consulting fee, lower hospitalization fee and lower inpatient treatment fee), to carry out caring services, the implementation of family wards, the introduction of the family wards and the hospitalization treatment fee, and the implementation of the community health services. Carry out love services, the implementation of family wards, family care, to provide residents with convenient, fast, economical, high-quality, inexpensive community health services, community doctors in the community no less than 15 days a month, chronic disease management home services per person no less than 10 times a year.
3, innovative operational mechanisms, the establishment of long-term mechanism of community health services, in-depth community, in-depth family, this time the community work plan to focus on the elderly, women, maternity, children, people with disabilities, to improve the quality of chronic disease management, to carry out a good yearly health checkup. Do a good job in the community medical first diagnosis system and two-way referral system, the full implementation of the sinking of public health personnel, strengthen the community health service institutions, hospitals, disease control centers, maternity and child health care hospitals functional positioning and division of responsibilities, strengthen the work of articulation and resource **** enjoyment, and actively carry out help and guidance and two-way communication, to facilitate the public near the medical care, to ensure medical safety. Children's insurance card, card rate of 100%, planning immunization rate of 95%, maternal management rate of 80%, hospital delivery rate of 95%, hospital delivery rate of 100% of high-risk pregnant women, and carry out postpartum visits to each pregnant woman no less than three times.
4, strengthen personnel management and talent training, the implementation of general practitioners, general practitioner nurses post training, community health service institutions to strictly implement the quota training program, arrange for the various trainers, and complete the task without compromise. Further standardize medical behavior, actively explore feasible salary allocation program, the establishment of community doctors performance assessment and evaluation mechanism, the implementation of job responsibility, target management and quantitative assessment, its assessment results and individual rewards and punishments linked to the full mobilization of community doctors to serve the initiative and enthusiasm, reflecting the priority of efficiency, more work more pay, rewards and punishment for laziness. Strict community health talent access system, the implementation of open recruitment, contract employment, the establishment and improvement of the resignation system, so that "the office to raise people, can enter and exit.
5, strengthen supervision and operational guidance, the implementation of centralized purchasing of drugs, unified distribution, standardization, compression of drug distribution links, reduce drug costs, choose and community common diseases, common diseases, basic medical drugs, so that residents enjoy the community basic inexpensive services, medical equipment, the strict implementation of government procurement.
6, continue to strengthen the publicity of community health and collaboration with the department, to improve the community residents' awareness; strengthen information reporting, the implementation of microcomputer network management, build a community information platform, the formation of up and down through, left and right connection, information **** enjoy a good networked to provide a scientific basis for the work of community health services, to ensure that the full implementation of community health work.
7, contributed to the establishment of a two-way referral system with higher hospitals, the community in the seriously ill patients, the first time to the scene, through the green channel of life, not through the outpatient registration and reception of direct escort such as the wards; recovery patients timely transfer to the community for rehabilitation, and regularly to the center of the equipment training, and under the guidance of community service personnel, by their family members to master health care, nursing, rehabilitation, massage and so on. Under the guidance of the community service personnel, the family members can master the health care, nursing care, rehabilitation, massage and other simple and practical skills, so that the patients can also carry out rehabilitation activities at home.
8, promote humanized services. The center adheres to the residents' health as the center, family as a unit, to carry out community health services. Dynamic testing and management of the health status of community residents, especially the elderly, women and children, and provide humanized services to meet the needs of special groups.
9. Strengthening the standardized management of community health. Strengthening the standardization, normative and scientific management of community health, gradually establishing and improving the basic standards, basic service norms and management methods of community health institutions, and improving various regulations.
10, focusing on the construction of community health services five types of institutions: general practitioner clinics, elderly care homes, community rehabilitation centers, family care centers and diagnostic centers
(1) general practitioner clinics
At the end of 2014 general practitioner clinics to reach 100% coverage, the general practitioner clinics to implement dynamic management, take the last few places out of the way, and carry out The annual assessment encourages competition between GP surgeries to ensure the overall quality of GP surgeries.
(2) Elderly care homes
Medical institutions in the community that are unused and under-utilized resources are converted into elderly care homes. According to market demand, the establishment of geriatric care homes, the admission of long-term chronic diseases of the elderly, terminally ill patients in the late stages of the disease, people with disabilities and other people in need of care services, to provide treatment, nursing care, hospice care, nutritional guidance and psychological counseling and a series of services.
(3) Community Rehabilitation Centers
Relying on hospitals of the second level and below, equipped with appropriate equipment and personnel, and according to the market demand, it strives to set up 3-5 community rehabilitation centers with a reasonable layout, which will provide a full range of treatments and auxiliary measures for people with dysfunctions due to illnesses and injuries.
(4) Family Care Centers
The unused and underutilized resources of medical institutions in the district are transformed into family care centers. Based on market demand, family care centers are established to undertake services such as community family care and home care.
(5) Establish a two-way referral system. Guiding the signing of the "two-way referral agreement" between the five types of institutions, the establishment of a two-way referral system that suits the needs of all parties. Through the establishment of the two-way referral system, community health services of all types of institutions to form a set of functional integrity, smooth operation, a reasonable division of labor system
11, to strengthen the construction of software
(1) personnel training
The end of 2014, community health service practitioners to participate in general medicine, community nursing, rehabilitation medicine and other related training rate of more than 90%, to achieve licensing. Realization of licensed to work.
(2) Health Education
Playing the main function of health education offices, the establishment of a sound community health education network, the rate of network construction reached 100%. Equipped with full-time and part-time health educators, increase training efforts, the training rate of more than 80%.
(3) Community Intervention for Chronic Non-Communicable Diseases with Hypertension as the Main Focus
With the cooperation of the disease control departments at the municipal and district levels, the following was achieved in 2014:
---- The rate of annual blood pressure measurements for the community's population aged 15 years old and above reached more than 60%;
---- 80% of the community's patients with high blood pressure received health education and took medication on a regular basis;
---- Salt intake per capita of residents is controlled at less than 10 grams;
---- More than 40% of residents participate in physical exercise.
(4) Maternal and child health care and family planning technical services
Playing the functions of maternal and child health clinics, relying on the cooperation of the Family Planning Commission, and focusing on reproductive health, it actively carries out women's five-phase education, five-phase health care, and the systematic management of children's health care in the community. at the end of 2015, it will achieve the following:
---- Actively carry out systematic health care for women in labor and childbirth, and basic health care for children, and reach 100% of the coverage rate with the community as a base. coverage to reach 100% and 98% respectively;
---- Carry out community-based child nutrition monitoring, intervention and guidance, so that the coverage rate of nutritional guidance for children aged 〈5 years old reaches 98%;
---- Pursue the Baby Friendly Action, and breastfeeding reaches 85%;
---- Carry out family planning technical services, and the rate of pregnancy management of the migrant population reaches 100% ;
---- The coverage rate of five-phase health care for women of childbearing age in the region has reached 90 percent.
13, the standardization of community health service institutions
---- strict approval of health-related products, strengthen the approval of community medical institutions, community practitioners, community practice nurses and the application of medical technology;
---- resolutely crack down on the community's illegal travelling doctors, outlawing the practice of medicine without a license, rectify the over-scope of the practice of medicine and other counterfeit community health service institutions;
---- promote the health system style of construction to the community extension, in the people's masses to establish a good image of community medical workers.
Sixth, the work steps
In accordance with the implementation of year by year, the distribution of the principle of advancing, in the grasp of the day-to-day recurrent work on the basis of the year to do a good job of the following key work.
1, 2010 work focus
(1) start a good community health work program.
(2) began to improve the residents' health records, the establishment of community residents "green life channel", benefiting poor residents. The implementation of full responsibility, full-day service, full care "three full" service mode.
(3) To make the knowledge rate, service utilization rate and service satisfaction rate of community health service of the residents of Xiangzhang Road community reach 81%, 71% and 75% respectively by the end of 2011.
(4). Changing concepts, updating the service model, take the initiative to carry out door-to-door services, extended services, continuous services and hospice services, the implementation of preferential policies for community health services, the specific implementation of the "five free and two lowered" (free of registration fee, free of the first fee, free of the clinic fee, free of injection fee, free of the health consultation fee, lower hospitalization fees and lower inpatient treatment costs), the development of love services, the implementation of family wards, the implementation of family wards, hospitalization treatment costs). Carry out caring services, the implementation of family wards, family nursing, to provide residents with convenient, fast, economical, high-quality, inexpensive community health services, community doctors to the community no less than 15 days a month, chronic disease management home service no less than 10 times per person per year.
(5) standardization of community health services
(6) increase efforts to establish good general practitioner clinics
2, 2011 work focus
(1) innovative operational mechanisms, the establishment of long-term mechanism of community health services, in-depth community, in-depth family, this time, the community work plan should be focused on the elderly, women, maternity, Children, the disabled, improve the quality of chronic disease management, carry out a good annual health checkup. Do a good job of community medical first-aid system and two-way referral system, the full implementation of the sinking of public health personnel, strengthen the community health service institutions, hospitals, disease control centers, maternal and child health hospitals, functional positioning and division of responsibilities, strengthen the work of articulation and resource **** enjoyment, and actively carry out help and guidance and two-way exchanges, to facilitate the public close to the medical care, to ensure medical safety. Pediatric insurance card, card rate of 100%, planning immunization rate of 95%, maternal management rate of 80%, hospital delivery rate of 95%, hospital delivery rate of 100% of high-risk pregnant women, and carry out post-partum visits no less than three times per pregnancy and childbirth.
(2) so that by the end of 2011 Xiangzhang Road community residents of community health services, service utilization rate and service satisfaction rate of 82%, 72% and 76% or more.
(3) Focusing on the construction of care homes for the elderly
(4) Carrying out the training of community health service practitioners to participate in general medicine, community nursing, rehabilitation medicine and other related training.
3, 2012 work focus
(1) to strengthen personnel management and talent training, the implementation of general practitioner, general practice nurse post training, community health service organizations should strictly implement the quota of training programs, arrangements for each trainer, and complete the task without fail. Further standardize medical behavior, actively explore feasible salary allocation program, the establishment of community doctors performance assessment and evaluation mechanism, the implementation of job responsibility, target management and quantitative assessment, its assessment results and individual rewards and punishments linked to the full mobilization of community doctors to serve the initiative and enthusiasm, reflecting the priority of efficiency, more work more pay, rewards and punishment for laziness. Strict community health talent access system, the implementation of open recruitment, contract employment, the establishment and improvement of the resignation system, so that "the office to raise people, can be in and out".
(2) to make the end of 2012 Xiangzhang Road community residents of community health services, service utilization rate and service satisfaction rate of 83%, 73% and 77% respectively.
(3) Focus on the construction of community rehabilitation centers. Utilizing the main function of health education institutes, a sound community health education network has been established, with the rate of network construction reaching 100%. Equipped with full-time and part-time health educators, increase training efforts, the training rate reached more than 80%.
4, 2013 work focus
(1) to strengthen supervision and operational guidance, the implementation of centralized procurement of drugs, unified distribution, standardization, compression of drug circulation links, reduce drug costs, selection and community common diseases, common diseases, mainly basic medical drugs, so that residents enjoy basic community affordable services, medical equipment, the strict implementation of government procurement.
(2) continue to strengthen the publicity of community health and collaboration with the department to improve the community residents' awareness; strengthen information reporting, the implementation of the microcomputer network management, build community information platform, the formation of up and down through, left and right connection, information **** enjoy a good networked to provide a scientific basis for the work of community health services, to ensure the full implementation of community health work.
(3) To make the knowledge rate, service utilization rate and service satisfaction rate of the residents of Balsam Road community on community health services reach more than 84%, 74% and 78% respectively by the end of 2013.
(4) Community Intervention for Chronic Non-Communicable Diseases, Mainly Hypertension
With the cooperation of the disease control departments at the municipal and district levels, to achieve the following in 2014:
---- The rate of annual blood pressure measurements for the community's population aged 15 years old and above reaches more than 50%;
---- 75% of the patients with high blood pressure in the community receive health education and take medication on a regular basis;
---- Salt intake per capita of residents is controlled below 11 grams;
---- More than 35% of residents participate in physical exercise.
(5) focusing on the construction of family care centers
5, the focus of 2014
(1) contribute to the establishment of a two-way referral system with the higher hospitals, the community in the seriously ill patients, the first time to the scene, through the green channel of life, not through the outpatient registration and reception of direct escort such as the wards; the recovery patients in a timely manner transferred to the community rehabilitation, and regularly go to the center for The patients in recovery are transferred to the community rehabilitation in time, and come to the center regularly for equipment training, and under the guidance of the community service personnel, their family members master some simple and practical skills such as health care, nursing, rehabilitation, massage, etc., so that the patients can also carry out rehabilitation activities at home.
(2) Promoting humanized services. The center adheres to the health of the residents as the center, the family as a unit, to carry out community health services. It conducts dynamic testing and management of the health status of community residents, especially the elderly, women and children, and provides humanized services to meet the needs of special groups.
(3) Strengthening the standardized management of community health. Strengthening the standardization, normalization and scientific management of community health, gradually establishing and improving the basic standards, basic service norms and management methods of community health institutions, and perfecting various rules and regulations.
(4) By the end of 2014, the knowledge rate, service utilization rate and service satisfaction rate of the residents of the Xiangzhang Road community for community health services will reach over 85%, 75% and 80% respectively.
(5) Community Intervention for Chronic Non-Communicable Diseases, Mainly Hypertension
With the cooperation of the disease control departments at the municipal and district levels, the following were achieved in 2014:
---- The annual blood pressure measurement rate of people over 15 years of age in the community reached more than 60%;
---- 80% of the patients with high blood pressure in the community received health education and took medication regularly;
---- Salt intake per capita of residents is controlled at less than 10 grams;
---- More than 40% of residents participate in physical exercise.
(6) Maternal and child health care and family planning technical services
Playing the functions of the Maternal and Child Health Institute, relying on the cooperation of the Family Planning Commission, and focusing on reproductive health, it actively carries out women's five-phase education, five-phase health care, and the systematic management of children's health care in the community. At the end of 2014 it will achieve the following:
---- Actively carry out systematic health care for mothers and basic health care for children, and the coverage rate of community-based health care will reach 100% respectively. coverage to reach 100% and 98% respectively;
---- Carrying out community-based child nutrition monitoring, intervention and guidance, so that the coverage of nutritional guidance for children aged 〈5 years old reaches 98%;
---- Implementing baby-friendly actions, with breastfeeding reaching 85%;
---- Carrying out family planning technical services, with the rate of pregnancy management for the migrant population reaching 100%.
---- The coverage rate of five-phase health care for women of childbearing age in the region reached 90%
VII. Guarantees
(a) to ensure that the necessary financial investment in community health services. Community health services set prevention, medical care, health care, rehabilitation, health education, family planning technical guidance "six in one", which contains many low-paid, unpaid work, such work should ensure the necessary economic investment, increase financial investment to ensure the healthy development of community health services. The government should increase financial investment.
(2) to speed up the process of urban medical and health system reform, rationalize various relationships, the implementation of various policies, for the development of community health services to create a good internal and external environment.
(iii). Promote policy protection. Comprehensive implementation of provincial, municipal and district "decision on accelerating the development of urban community health services" and its supporting documents, improve the corresponding policies and provincial, municipal and district supporting funds, increase the public **** health funding, strengthen the construction of institutions and training of personnel, the development of feasible operational programs, and community health services are all included in the social health insurance designated institutions, in order to promote the development of community health services. Social health insurance designated institutions, to promote the development of community health services to provide strong support and policy protection.