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目的:通过对随访模式的探索,最大程度提高农村责任医生随访覆盖率与随访率;方法:用社区诊断作为效果评估方法,并建立对照组,开展个案、集体、家庭辅助、委托、电话、门诊等模式进行随访;结果:通过3年随访模式研究,随访覆盖率、随访率得到明显提高,农村居民满意度、知识知晓率、高血压控制率等相关指标得到明显提高;结论:责任医生多种随访模式综合应用是开展公共卫生服务的有力手段,可以有效推动慢病随访管理、重点人群管理、健康教育、高危人群干预服务等工作全面开展。
OBJECTIVE: To explore the follow-up mode to maximize follow-up coverage and follow-up rate of rural responsible doctors.Methods: Using community diagnosis as the evaluation method and establishing a control group to carry out case, group, family support, trust, telephone, outpatient Follow-up was made in the follow-up study. Results: After 3-year follow-up study, follow-up coverage rate and follow-up rate were significantly increased. Satisfaction of rural residents, awareness rate of knowledge and rate of hypertension control were significantly improved.Conclusion: The comprehensive application of follow-up mode is a powerful means to carry out public health services, which can effectively promote the follow-up management of chronic diseases, key population management, health education and intervention services for high-risk groups.