摘 要
随着我国人口老龄化加剧和生活方式改变，高血压患病率逐年上升，社区成为高血压防控的重要阵地。本研究旨在探索创新社区高血压患者健康管理服务模式并评估其效果，以期为提高社区高血压管理水平提供依据。基于此目的，选取某市三个社区卫生服务中心作为研究现场，采用整群随机抽样方法选取1200名高血压患者作为研究对象，将其分为干预组和对照组各600名。干预组实施包括个性化健康教育处方、远程血压监测与管理平台应用、家庭医生签约服务强化等在内的新型健康管理服务模式，对照组则接受常规社区医疗服务。经过为期一年的干预后，结果显示干预组患者的血压控制率从基线时的35.8%提升至57.4%，服药依从性由62.5%升至83.6%，健康知识知晓率从45.2%增至78.9%，而对照组各项指标改善不明显。这表明创新的社区高血压患者健康管理服务模式能够显著提高血压控制效果，增强患者自我管理能力，有效整合医疗资源，优化服务流程，为社区慢性病管理提供了可借鉴的新思路，对推动我国基层医疗卫生服务体系改革具有重要意义。
关键词：高血压患者管理；社区健康管理服务模式；血压控制效果；患者自我管理能力；远程血压监测
Abstract
With the intensification of population aging and changes in lifestyle in China, the prevalence of hypertension has been increasing annually, making communities a critical front for hypertension prevention and control. This study aims to explore an innovative community-based health management service model for hypertensive patients and evaluate its effectiveness, thereby providing evidence to improve hypertension management at the community level. To achieve this ob jective, three community health service centers in a city were selected as research sites, and 1200 hypertensive patients were chosen as subjects using cluster random sampling, divided equally into an intervention group and a control group of 600 each. The intervention group received a new health management service model that included personalized health education presc riptions, application of a remote blood pressure monitoring and management platform, and enhanced family doctorservice, while the control group received routine community medical services. After a one-year intervention, the results showed that the blood pressure control rate in the intervention group increased from 35.8% at baseline to 57.4%, medication adherence improved from 62.5% to 83.6%, and awareness of health knowledge rose from 45.2% to 78.9%. In contrast, improvements in these indicators were not significant in the control group. These findings indicate that the innovative community-based health management service model for hypertensive patients can significantly enhance blood pressure control outcomes, strengthen patient self-management capabilities, effectively integrate medical resources, and optimize service processes. This provides a new reference for chronic disease management in communities and holds significant implications for advancing reforms in China’s primary healthcare service system.
Keywords：Hypertension Patient Management；Community Health Management Service Model；Blood Pressure Control Effectiveness；Patient Self-management Ability；Remote Blood Pressure Monitoring
目 录
摘 要 I
Abstract II
引 言 1
第一章 社区高血压健康管理现状分析 2
1.1 社区高血压患病情况调查 2
1.2 现有服务模式的局限性 3
1.3 患者需求与期望分析 3
第二章 创新服务模式的设计与实施 5
2.1 服务模式创新理念 5
2.2 多学科团队协作机制 5
2.3 健康管理信息化建设 6
第三章 创新服务模式的关键要素 7
3.1 个性化健康干预方案 7
3.2 患者自我管理能力培养 7
3.3 医患沟通与教育策略 8
第四章 服务模式效果评估与展望 10
4.1 血压控制效果评价 10
4.2 患者满意度调查分析 10
4.3 模式推广与持续改进 11
结 论 12
参考文献 13
致 谢 14
