关键词: 计算机通信网络；医院-社区-家庭；伤口造口患者；延续性护理；医联体

Abstract: The intelligent care team was built up based on the hospital high quality resources and the opportunity of medical partnership. We established the hospital-community-family intelligent care by the aid of phone application and the wound/stoma care clinic. Through the model, we provided convenient and high quality services to the patients. Besides, a continuous care network was also set up. All the efforts we made were aimed to increase the number of visiting community health centers, decrease the average cost of dressing change, and improve the sense of gain for patients. Thus, we can improve the specialized nursing care level in the community and promote the policy implementation of hierarchical medical system.

Key words: computer communication network; hospital-community-family; patients with wound/stoma; continuous care; integrated health care organization