Some family doctors have also opened a special clinic for diabetes... 60% of residents in this district of Shanghai are diagnosed and treated in Fengxian | residents | community

Fengxian is located in the remote suburbs, with limited medical resources. Community diagnosis and treatment have become the top priority for residents' health. How to build a good network base to serve the people?

The reporter recently learned from the district health commission that based on the actual situation of the region, taking into account the size of the service population and the trend of population introduction, the district health commission is promoting the horizontal integration of community health resources. Residents are willing to "vote with their feet" to choose the community, and the solid foundation and warm service of community family doctors are indispensable. Data shows that there are currently 549 general practitioners in Fengxian District. Last year, the proportion of community diagnosis and treatment accounted for 49% of the total diagnosis and treatment in the district. In the first half of this year, the proportion of community diagnosis and treatment has increased to 60%.

Standardize the cultivation and practice of "internal skills" in family medicine

Wang Tao is a family doctor at the Xidu Community Health Service Center in Fengxian District. She has stuck to the community for ten years. Now she has signed with more than 1900 community residents and opened her own diabetes clinic. In managing chronic disease patients in the community, Wang Tao integrates his learned knowledge with practice to form a unique management model: grouping contracted residents according to their own characteristics, regularly following up with "group members", reminding them of precautions, and conducting regular follow-up visits.

Mr. Zhang, who suffers from multiple illnesses, used to repeatedly travel to third level hospitals in the city, which was troublesome. After signing with Dr. Wang Tao, he no longer had to go far. He only needed to follow the doctor for regular follow-up visits and referrals if needed. "Dr. Wang is my family doctor, so if you have any health problems, just contact her!"

To reassure contracted residents, the strength and confidence of family doctors are behind it. The reporter learned that Wang Tao has successively studied in the Endocrine Metabolism Department of the Sixth Hospital of the city, the Emergency Department of the Central Hospital of Fengxian District, and the Neurology Department. He has also undergone a year of devil training at the Zhongshan Xidu General Practice Teaching Outpatient Clinic to lay a solid foundation.

Now, as the head of the family doctor's studio and the head of the ward, she has also formed a closed-loop and orderly management of the whole process of diagnosis and treatment, education, and follow-up for diabetes patients. At the same time, she has organized the team to carry out emergency drills every month to respond to the emergency treatment that may occur at any time in the ward and continue to practice "internal skills" to serve patients.

General outpatient department focuses on the combination of all specialties

In fact, there are quite a few general practitioners like Wang Tao who combine all specialties in Fengxian. The reporter learned that many community health service centers in Fengxian have made general outpatient clinics the main battlefield, providing full coverage and expanding the number of consultation rooms according to the actual needs of residents. Last year, 20 community health service centers had a total of 1.816 million general practitioner outpatient visits, accounting for 85.2% of the total outpatient and emergency visits in the community. At the same time, every general practitioner was encouraged to choose their preferred specialized field of study to enhance their ability to provide home care services.

The Xidu Community Health Service Center, established 8 years ago by Zhongshan Hospital affiliated with Fudan University, is the first general practice remote teaching center in this area. Led by Professor Zhu Zhuzhu from the General Practice Department of Zhongshan Hospital, the team has been deeply cultivating and researching, providing training for Xidu general practice doctors and young general practitioners, practicing the diagnosis and treatment of common and chronic diseases in the community, and establishing a general practice concept. Over the past 8 years, this "Zhongshan Community" general practice teaching clinic has explored a unique development path for community health service centers, leading 124 trainees in teaching regulations and 25 community general practitioners, cultivating a strong family medicine team for Xidu.

Liu Jianfeng, a general practitioner at Nanqiao Town Community Health Service Center, is very interested in cardiology. Eight years ago, the center actively coordinated and arranged for him to go to the cardiology department of Fengxian District Central Hospital for further studies. At the same time, they established a community cardiac rehabilitation team and collaborated with cardiology experts to establish "Dr. Liu's Heart Health Home". While serving residents, they continuously expanded the career prospects of general practitioners and made more young doctors willing to invest in home medicine.

Enriching the connotation of family doctor services

To meet the health needs of suburban residents, the community layout is constantly expanding. According to the Fengxian District Health Commission, during the 14th Five Year Plan period, three community health service centers, Nanqiao, Jinhai, and Xidu, as well as the Fengpu Community Gaozhou Road Outpatient Department, will be newly built and put into use in the district. This year, three community health service centers in Jinhui, Qingcun, and Haiwan will officially open their new locations. The construction of three community health service centers in Zhelin, Ping'an, and Guangming, as well as the Fengcheng community outpatient department, are also actively being prepared. The relevant person in charge told reporters that after incremental expansion and stock revitalization, the standardized community health service center in Fengxian will achieve full street coverage by 2025.

With adequate hardware, family doctors will be able to play a greater role. At present, relying on the family doctor contract service network, 152800 people in the area have completed health risk assessments for key populations. One person, one file, and dynamic updates have been established for key populations, and classified management has been implemented according to the red, yellow, and green risk levels. Community health service centers can achieve on-site appointments with experts from second and third level hospitals through the local home medical platform, and set up fast diagnosis and treatment channels to enhance the perception of graded referral.

With the continuous enrichment of family doctor services, Fengxian will comprehensively promote community rehabilitation centers and complete the construction of two city level demonstration community rehabilitation centers, Nanqiao and Xidu. Within this year, three city level demonstration community rehabilitation centers, Jinhui, Haiwan, and Fengpu, will be promoted to provide functional assessment, rehabilitation treatment, nursing, referral and other services for the elderly, children, disabled people, and people with limb dysfunction who have rehabilitation needs, better caring for the health of Fengxian's 1.14 million permanent residents.