医养随访一体机：基于互联网的医养结合发展展望

　　医养结合指的是医疗卫生和养老服务相结合，互联网技术运用到医养结合事业中，需要充分利用现有健康、养老等信息平台，打造覆盖家庭、社区和机构的智慧健康养老服务网络，推动老年人的健康和养老信息共享、深度开发和合理利用。截至2019年底，全省户籍人口7865.82万人中，60岁及以上老年人口1834.16万人，占比23.32%；65岁及以上老年人口1330.29万人，占比16.91%。南京市六合区共有60周岁以上老年人147560人，占户籍人口总数的21%，庞大的老年人群急需较为便捷完善的医疗养老服务体系建立。互联网+医养结合模式可以提高健康养老服务质量和效率，逐步满足老年人日益增长的健康养老服务需求。

　　The combination of medical care and elderly care refers to the combination of medical care and elderly care services. When Internet technology is applied to the combination of medical care and elderly care, it is necessary to make full use of the existing health, elderly care and other information platforms, build a smart health elderly care service network covering families, communities and institutions, and promote the sharing, in-depth development and rational use of health and elderly care information for the elderly. By the end of 2019, among the 78.6582 million registered residence in the province, 18.3416 million were aged 60 and above, accounting for 23.32%; The elderly population aged 65 and above is 13.3029 million, accounting for 16.91%. There are 147560 elderly people over 60 years old in Liuhe District of Nanjing City, accounting for 21% of the total registered residence population. A large number of elderly people urgently need to establish a more convenient and complete medical and old-age service system. The combination of Internet plus and health care can improve the quality and efficiency of health care services for the elderly and gradually meet the growing demand for health care services for the elderly.

　　医养结合的现状

　　The current situation of the integration of medical care and elderly care

　　医养结合主要依托四种模式，其医养结合途径和效果如下所示。

　　The integration of medical care and elderly care mainly relies on four models, and the pathways and effects of this integration are as follows.

　　（1）居家养老。以15个社区卫生服务中心为主体，开展老年人的健康管理工作，采取医护人员定期上门家医签约服务的模式。效果：2010年10月统计，我区老年人健康管理已完成6.9万人，健康体检已完成5.4万人。

　　(1) Home care for the elderly. With 15 community health service centers as the main body, we carry out health management work for the elderly, adopting a model of regular home doctor contract services by medical staff. Effect: According to statistics in October 2010, 69000 elderly people in our district have completed health management, and 54000 people have completed health examinations.

　　（2）社区养老中心。①社区帮助居家养老服务中心为老人提供包括健康管理、药事管理以及康复护理等方面的入户助医服务。②设立家庭医生工作室开展医疗服务。效果：①社区工作者助医已覆盖全区105个社区。②已设立家庭医生工作室20个。

　　(2) Community elderly care center. ① Community assisted home-based elderly care service centers provide home-based medical assistance services for the elderly, including health management, medication management, and rehabilitation care Establish a family doctor studio to provide medical services. Effect: ① Community workers' medical assistance has covered 105 communities in the entire district. ② 20 family doctor studios have been established.

　　（3）医护型养老机构。养老机构按标准建设医务室，配备医务人员。效果：全区二十多家养老机构按标准建设医务室，其中特困供养机构100%设置医务室。

　　(3) Medical and nursing type elderly care institutions. Elderly care institutions shall construct medical rooms according to standards and equip them with medical personnel. Effect: More than 20 elderly care institutions in the entire district have built medical rooms according to standards, among which 100% of the extremely poor support institutions have set up medical rooms.

　　（4）基层医疗机构。医疗卫生机构设置用于康复、护理的养老床位，与一般养老机构统一备案、统一监管。效果：六合区竹镇镇社区卫生服务中心增加养老床位30张，医护人员8名。

　　(4) Primary healthcare institutions. Medical and health institutions set up elderly care beds for rehabilitation and nursing, which are registered and supervised uniformly with general elderly care institutions. Effect: Zhuzhen Town Community Health Service Center in Liuhe District has added 30 elderly care beds and 8 medical staff.

　　互联网+的优势

　　Advantages of Internet plus

　　（1）合理分配医疗资源。我国目前面临医疗资源分配不均的问题，尤其是发达地区与贫困地区的医疗资源差距过大，通过大力推广的互联网+医养结合事业能一定程度缓解这种情况，无论是居家，在社区、养老机构或者是基层医疗机构，远程医疗是诊断和治疗的一种新的服务形式，能够一定程度减少老年患者来回奔波医院的不便及感染其他疾病的风险。慢性病、轻症复诊，化验检查报告解读、远程会诊、联合门诊、远程查房等成为可能。

　　(1) Reasonably allocate medical resources. At present, China is facing the problem of uneven distribution of medical resources, especially the large gap between developed and poor areas in medical resources. Through the vigorous promotion of the Internet plus+medical care and elderly care combination business, this situation can be alleviated to a certain extent. Whether at home, in communities, pension institutions or grass-roots medical institutions, telemedicine is a new form of service for diagnosis and treatment, which can reduce the inconvenience of elderly patients traveling back and forth to hospitals and the risk of infection with other diseases to a certain extent. Chronic and mild disease follow-up visits, interpretation of laboratory test reports, remote consultations, joint clinics, remote rounds, etc. have become possible.

　　（2）优化服务流程。在互联网+医养结合事业管理过程中使用互联网和人工智能技术，可依托互联网、物联网、云计算、大数据、智能养老和健康设备等信息技术和智能硬件产品，汇聚线上线下资源，精准对接需求与供给，为老年人提供“点单式”职能服务。能够准确完成健康档案管理、信息调阅、慢病复诊、预约转诊、防跌倒、防走失和紧急救护等服务，同时能够实时监管服务质量。

　　(2) Optimize service processes. The use of Internet and artificial intelligence technology in the management process of Internet+medical care integration can rely on information technology and intelligent hardware products such as the Internet, the Internet of Things, cloud computing, big data, intelligent elderly care and health equipment, gather online and offline resources, accurately connect demand and supply, and provide "point to point" functional services for the elderly. It can accurately complete services such as health record management, information retrieval, chronic disease follow-up, appointment referral, fall prevention, loss prevention, and emergency rescue, while also being able to monitor service quality in real time.

　　（3）提高管理效率。目前家庭医生签约服务是医养结合运用较为广泛的模式，2018年3月正式上线运行“六合区家庭医生签约服务管理系统”，并与公共卫生、基本医疗服务等信息系统互联互通，实现通过信息化手段，监测签约数量、服务内容、服务次数等相关信息并与市级家庭医生签约服务信息系统对接，适时上传相关数据。同时使用家庭医生APP，实现了居民建档、家庭医生签约、慢病管理、随访评估、健康教育、健康体检、中医体质辨识、预约转诊等功能服务。配备了160套移动随访一体机，减轻家庭医生团队的工作量，进一步提高签约服务质量。通过随访一体机与家庭医生APP结合，实现测量血压、体温、血糖、血氧饱和度、脉搏、心电等多项检查，并基本实现服务数据与居民健康档案实时同步。从家庭医生签约服务这一个模式可以窥见互联网+带来的管理优势。

　　(3) Improve management efficiency. At present, the family doctor contract service is a widely used model that combines medical care and elderly care. In March 2018, the "Liuhe District Family Doctor Contract Service Management System" was officially launched and operated, and it is interconnected with information systems such as public health and basic medical services. Through information technology, it monitors the number of contracts, service content, service frequency, and other related information, and connects with the municipal family doctor contract service information system to upload relevant data in a timely manner. At the same time, the family doctor app has been used to provide functional services such as resident registration, family doctor contract signing, chronic disease management, follow-up evaluation, health education, physical examination, traditional Chinese medicine constitution identification, and appointment referral. Equipped with 160 sets of mobile follow-up all-in-one machines, it reduces the workload of the family doctor team and further improves the quality of contracted services. By combining the follow-up all-in-one machine with the family doctor app, multiple examinations such as blood pressure, body temperature, blood glucose, blood oxygen saturation, pulse, and electrocardiogram can be measured, and real-time synchronization of service data with residents' health records can be basically achieved. The management advantages brought by Internet plus can be seen from the family doctor contract service model.

　　（4）创新服务模式。互联网+不但能提供传统意义上的健康服务，同时还能根据新时代家庭特点，创新服务模式，通过智能穿戴设备和智能家居设备，老人使用设备时的数据会实时上传到平台生成报告，如果有突发意外或数据警报，平台会根据情况及时处理。年长的老人佩戴手环时，信息可联动平台进行监管，平台可以在后台根据智能手环的定位及时跟踪老人位置，确保老人安全，智能机器人的出现甚至可以实现情感陪护功能。这些为高龄老人独居提供了更加可行的解决方案。

　　(4) Innovative service model. Internet plus can not only provide health services in the traditional sense, but also innovate the service mode according to the characteristics of the new era family. Through intelligent wearable devices and smart home devices, the data of the elderly when using the device will be uploaded to the platform in real time to generate a report. If there is a sudden accident or data alarm, the platform will deal with it in a timely manner according to the situation. When elderly people wear wristbands, the information can be monitored through a platform that can track their location in a timely manner based on the positioning of the smart wristband in the background, ensuring their safety. The emergence of smart robots can even achieve emotional companionship functions. These provide more feasible solutions for elderly people living alone.

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