摘要实施"院前-院中-院后"慢性病闭环管理,是提升当前慢性病管理效能的有效方法.作者简述了宁夏地区基层实施慢性病闭环管理的可行性、建设内容和亟待解决的问题,重点阐述了构建面向多病种的慢性病管理路径、实施基于"三师共管"的慢性病闭环管理、推进基层医师的培养和提升规范化管理水平、建立以社区为中心的慢性病三级防治体系、推广慢性病管理与干预信息支撑平台等内容,以提高基层慢性病管理实施效果,提升患者健康水平和生存质量,降低人民群众的经济负担.

abstractsThe pre-during-post hospital closed-loop management of chronic diseases is an efficient way to upgrade the current chronic disease management level. The authors described the feasibility, what to build and imperative problems in implementing such a closed-loop management in primary level in Ningxia. The introduction focused on the construction of a chronic disease management path for multiple diseases, the implementation of a closed-loop management model for chronic diseases based on the " three in one model ( specialist-family physician-health manager )" , the promotion of primary physician training and standardization management level, as well as the establishment of a community-centered three-level prevention and treatment system for chronic diseases. These efforts aim at promotion of chronic disease management outcomes, elevation of patients' health and quality of life, and minimization of people's economic burden.