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社区卫生服务中心在为城市和农村居民提供“预防、保健、医疗、康复、健康教育”等全方位的服务是应对老龄化社会最经济适宜的健康管理措施。城乡区域慢性非传染性疾病的健康管理是通过充分发挥社区信息网络平台的作用,以健康教育和健康促进为主要手段,针对共同危险因素,在全人群和目标人群中引入医护防团队干预、社区综合防制、倡导自我管理相结合的模式,不仅有效利用了社区的资源,大大提高卫生保健服务的公平性和效率,而且在关注居民的生存质量,提高健康水平中发挥了非常重要的作用,这是慢性病管理持续发展的可行方法和主要手段。
Community Health Service Centers provide a full range of services such as prevention, health care, medical care, rehabilitation and health education to urban and rural residents to provide the most economical and appropriate health management measures in an aging society. The health management of chronic non-communicable diseases in urban and rural areas is mainly through giving full play to the role of community information network platform, taking health education and health promotion as the main measures, introducing common prevention and treatment team intervention in the whole population and target population in response to common risk factors, The combination of prevention and control and advocacy of self-management not only makes effective use of community resources and greatly improves the fairness and efficiency of health care services, but also plays a very important role in paying attention to the residents’ quality of life and improving their health. This is a feasible method and the main means for the sustainable development of chronic disease management.