摘要： 推進基層醫(yī)防深度融合，做實家庭醫(yī)生簽約服務，是深化醫(yī)藥衛(wèi)生體制改革的重要任務。本文以高血壓、糖尿病健康管理為突破口，以家庭醫(yī)生簽約服務為載體，探索基層醫(yī)防融合健康管理服務模式。通過基層醫(yī)療衛(wèi)生機構(gòu)內(nèi)部的“管理融、隊伍融、服務融、績效融、信息融”，實現(xiàn)由全科醫(yī)生團隊統(tǒng)攬醫(yī)療和公共衛(wèi)生服務，做到一次門診既滿足患者診療需求，同時也完成必需的基本公共衛(wèi)生服務。醫(yī)防“五融合”提供“防、治、管”一體的健康管理，既有利于提升服務質(zhì)量，增強居民獲得感，又有利于推動機構(gòu)內(nèi)部橫向的基本醫(yī)療和基本公共衛(wèi)生的融合及機構(gòu)外部縱向的醫(yī)療資源整合。

關鍵詞: 初級衛(wèi)生保健, 社區(qū)衛(wèi)生服務, 衛(wèi)生服務研究, 基層醫(yī)療衛(wèi)生機構(gòu), 醫(yī)防融合, 慢性病管理, 健康管理服務模式, 重慶

Abstract: Promoting the delivery of intensive integrated essential medical services and national essential public health services，as well as contracted family doctor services by primary care settings，are important tasks to deepen the reform of the pharmaceutical and healthcare system. To explore an appropriate health management mode for delivering both essential medical services and national essential public health services in primary care，we have tried to provide such services for hypertensive and diabetes patients by a contracted general practitioner team via five integrated measures（integration of management，workforce，scope items，performance assessment，and information of the two types of services）. In this way，the patient could access to both medical services and national essential public health services in an outpatient consultation. This kind of comprehensive health management（consisting of preventive，treatment and management services） is conducive to improving the service quality and residents' sense of gain，as well as promoting the intra-hospital horizontal integration of such services and inter-hospital vertical integration of medical resources.

Key words: Primary health care, Community health services, Health services research, Primary health care institutions, Integration of treatment and prevention, Chronic disease management, Health management service mode, Chongqing

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