CN113035304A - 一种用于帕金森病患者的服务管理平台 - Google Patents
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Abstract
本发明提供了一种用于帕金森病患者的服务管理平台，包括社区服务系统和医院服务系统；所述社区服务系统包括社区机构，所述医院服务系统包括基层医疗卫生服务机构、康复机构和健康管理机构；所述社区机构对帕金森病患者的信息进行收集并传输给基层医疗卫生服务机构，所述基层医疗卫生服务机构给出评估并向社区机构给出建议，所述社区机构对帕金森病患者进行随访并进行登记并制定管理计划，康复机构根据管理计划制定康复训练课程并对帕金森病患者的的照料者进行培训。采用本发明的优点：对社区的老年期退行性疾病的预防和干预、失能失智的社区康复具有较强的实用价值，有力加强和完善现有的基本公共卫生服务工作。
Description
技术领域
本发明涉及帕金森病患者的服务管理平台，特别涉及一种用于帕金森病患者的服务管理平台。
背景技术
截止到2019年底，我国60岁及以上人口总数超过2.5亿，占总人口的18.1％，其中65岁及以上1.76亿占总人口的12.6％。在我国65岁以上老年人中，慢性病的死亡占总死亡的比例达到了90％以上，失能老年人4000万以上，其中以阿尔茨海默病(Alzheimer'sdisease,AD)和帕金森病(Parkinson's disease,PD)为主的神经系统疾病是造成失能的主要原因，其死因构成上升至第八位。
帕金森病是老年期常见的神经退行性疾病，根据以往调查结果显示，我国65岁及以上老年人群的帕金森病患病率约为1.7％。目前我国帕金森病患者总数在300万以上。帕金森病不仅致残率高、中晚期病人多、治疗效果差、治疗费用昂贵、长期护理需求等给家庭带来沉重的精神和经济负担，成为消耗国家医疗资源的“黑洞”，已被称为继癌症和心脑血管疾病之后，影响老年健康的第三大“杀手”，对国家和地区的卫生、福利、社会服务等各相关部门产生巨大挑战，已引起各国政府和卫生人员的高度关注。
因此，如何普遍开展有效的早期筛查，提高早期诊断率和加强疾病的规范管理，最终达到推迟或延缓疾病发生，这是目前世界各国所关注的防控策略。2019年，在国家卫健委老龄健康司下发的《关于建立完善老年健康服务体系的指导意见》(国卫老龄发〔2019〕61号)中明确要求：“加强老年人群重点慢性病的早期筛查、早期干预及分类管理，积极开展阿尔茨海默病、帕金森病等神经退行性疾病的早期筛查和健康指导。实施失能预防项目，宣传失能预防核心信息，降低老年人失能发生率。”
但目前在主要承担老年健康体检与慢病管理的基层医疗卫生服务机构中，服务人员对老年神经退行性疾病的认识不足，既没有医疗机构和康复机构专家协助，也没有统一的管理技术与规范做指导，无法在社区对居家帕金森病患者开展病情评估及有效管理，对照料人员进行康复和照料知识与技能的培训。
发明内容
针对现有技术中的上述不足，本发明提供了一种用于帕金森病患者的服务管理平台，其对社区的老年期退行性疾病的预防和干预、失能失智的社区康复具有较强的实用价值，有力加强和完善现有的基本公共卫生服务工作。
为了达到上述发明目的，本发明采用的技术方案为：
一种用于帕金森病患者的服务管理平台，包括社区服务系统和医院服务系统；所述社区服务系统包括社区机构，所述医院服务系统包括基层医疗卫生服务机构、康复机构和健康管理机构；
所述社区机构对帕金森病患者的信息进行收集并传输给基层医疗卫生服务机构，所述基层医疗卫生服务机构给出评估并向社区机构给出建议，所述社区机构对帕金森病患者进行随访并进行登记并制定管理计划，康复机构根据管理计划制定康复训练课程并对帕金森病患者的的照料者进行培训，健康管理机构根据康复机构的计划对效果进行评估并反馈给社区机构。
作为改进，所述康复机构根据不同的帕金森病患者的情况制定特定的计划，并根据社区机构的随访登记周期性的对计划进行改变。
作为改进，所述社区机构对帕金森病患者进行登记均以电子表格的形式并以网略传输的形式传输给康复机构。
作为改进，所述康复机构对照料者进行培训采用线上和线下相结合的形式。
本发明的有益效果为：
以病人为中心，结合疾病的特点和基层医疗卫生服务机构的工作实际需求，不仅能够帮助提高基层医疗卫生工作人员对帕金森病的防控能力，而且也为帕金森病患者的居家-社区管理提供了一套科学、系统的管理方法。对社区的老年期退行性疾病的预防和干预、失能失智的社区康复具有较强的实用价值，有力加强和完善现有的基本公共卫生服务工作。
附图说明
图1为本发明的平台流程示意图；
具体实施方式
下面结合附图来进一步说明本发明的具体实施方式。
为了使本发明的内容更容易被清楚地理解，下面将结合本发明实施例中的附图，对本发明实施例中的技术方案进行清楚、完整地描述。
如图1所示，一种用于帕金森病患者的服务管理平台，包括社区服务系统和医院服务系统；所述社区服务系统包括社区机构，所述医院服务系统包括基层医疗卫生服务机构、康复机构和健康管理机构；
所述社区机构对帕金森病患者的信息进行收集并传输给基层医疗卫生服务机构，所述基层医疗卫生服务机构给出评估并向社区机构给出建议，所述社区机构对帕金森病患者进行随访并进行登记并制定管理计划，康复机构根据管理计划制定康复训练课程并对帕金森病患者的的照料者进行培训，健康管理机构根据康复机构的计划对效果进行评估并反馈给社区机构。
所述康复机构根据不同的帕金森病患者的情况制定特定的计划，并根据社区机构的随访登记周期性的对计划进行改变。
所述社区机构对帕金森病患者进行登记均以电子表格的形式并以网略传输的形式传输给康复机构。
所述康复机构对照料者进行培训采用线上和线下相结合的形式。
该平台使用过程中，康复机构也可以对类似情况的病人进行分组管理，制定组内统一的计划，如果病人的恢复情况不一致可以根据后期情况进行调整，从而减少工作强度。
以上所述仅为本发明专利的较佳实施例而已，并不用以限制本发明专利，凡在本发明专利的精神和原则之内所作的任何修改、等同替换和改进等，均应包含在本发明专利的保护范围之内。
Claims (4)
1.一种用于帕金森病患者的服务管理平台，其特征在于，包括社区服务系统和医院服务系统；所述社区服务系统包括社区机构，所述医院服务系统包括基层医疗卫生服务机构、康复机构和健康管理机构；
所述社区机构对帕金森病患者的信息进行收集并传输给基层医疗卫生服务机构，所述基层医疗卫生服务机构给出评估并向社区机构给出建议，所述社区机构对帕金森病患者进行随访并进行登记并制定管理计划，康复机构根据管理计划制定康复训练课程并对帕金森病患者的的照料者进行培训，健康管理机构根据康复机构的计划对效果进行评估并反馈给社区机构。
2.根据权利要求1所述的一种用于帕金森病患者的服务管理平台，其特征在于：所述康复机构根据不同的帕金森病患者的情况制定特定的计划，并根据社区机构的随访登记周期性的对计划进行改变。
3.根据权利要求2所述的一种用于帕金森病患者的服务管理平台，其特征在于：所述社区机构对帕金森病患者进行登记均以电子表格的形式并以网略传输的形式传输给康复机构。
4.根据权利要求1所述的一种用于帕金森病患者的服务管理平台，其特征在于：所述康复机构对照料者进行培训采用线上和线下相结合的形式。
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Application publication date: 20210625 |