关键词: 医院-社区联动；慢性伤口；照护；模式；医联体

Abstract: Objective: To establish a chronic wound care model of hospital community linkage and to explore its effects on health professionals' examination performance and patient's satisfaction level. Methods: Firstly, we established a team of chronic wound care of hospital community linkage. Team regulations and personal responsibilities were developed. The wound care skills and patient management ability of community health professionals were trained through chronic wound care management platform in respective communities. The chronic wound care model was accordingly built up through the measures we took. The self-control study design was used. We compared the number of patients admitted to the community stations, patients' satisfaction with the care, and community nurses' knowledge and skill levels before and after the model used. Results: After the implementation of the model in 2015, a total of 54 community stations joined in the chronic wound care platform. A total of 53 patients with chronic wounds were treated by this model and 51 patients of them were totally cured with a cure rate of 96.23%. During the model was implemented, we totally conducted 88 on-site consultations and 452 remote directions. Before and after the model implementation in 2015 and 2018, the performance regarding the examinations passing rates community health professionals had been improved (P<0.001). Patients with chronic wound had increased satisfaction level (P<0.001). Conclusion: The chronic wound care model of hospital community linkage can improve the wound management abilities of health professionals in the community. It can standardize the chronic wound management strategies as well. It is helpful to ensure the treatment continuity of patients and improve their senses of gain in medical treatment. On the other hand, it is also beneficial to classified wound management and improve the nursing care system of chronic wound.

Key words: hospital community linkage; chronic wound; care; model; integrated health care organization