“主动健康”理念下老年慢病“居家–社区–医院”中西医协同服务模式的构建
Construction of a “Home-Community-Hospital” Chinese and Western Medicine Collaborative Service Model for Chronic Diseases in the Elderly under the Concept of “Active Health”

我国慢病管理目前尚存在资源总量不足、分配不均，管理结构不合理等问题，不能满足老年慢病患者多样化需求。“居家–社区–医院”中西医协同服务模式是一种基于云计算、数据分析的新型医养结合服务模式，将中医与西医结合协同诊疗，实现慢病的连续动态管理，并构建多元主体参与的慢病管理体系，逐步实现“主动健康”。该一体化智慧管理服务模式可平衡资源分配，规范慢性病管理路径，为我国慢病管理工作提供参考，但由于政策制度尚未完善，医疗服务能力有待提高，该模式目前推行较为困难，未来可进一步完善制度保障，增强慢病管理的医疗服务能力，以满足老年慢病患者多样化的需求。
At present, China’s chronic disease management is still characterized by insufficient and uneven distribution of total resources and an irrational management structure, which cannot meet the diversified needs of elderly patients with chronic diseases. The “home-community-hospital” Chinese and Western medicine synergistic service model is a new type of combined medical and nursing service model based on cloud computing and data analysis, which combines Chinese medicine and Western medicine in synergistic diagnosis and treatment, realizes continuous and dynamic management of chronic diseases, and builds a chronic disease management system with the participation of multiple subjects, gradually realizing the principle of “active health”. This integrated intelligent management service model can balance the distribution of resources, standardize the path of chronic disease management, and provide a reference for the management of chronic diseases in China. However, due to the fact that the policy system has not yet been perfected and the capacity of medical services has yet to be improved, it is difficult to implement this model, and the system can be further improved in the future to enhance the capacity of medical services for the management of chronic diseases, so as to satisfy the diversified needs of the elderly patients with chronic diseases.