基于慢病轨迹的县域连续性服务供需均衡分析与优化策略研究

作为新时代全民健康的严峻挑战，慢病防治具有“长期、多次、多机构”服务的特点，进一步凸显协作、整合的服务提供模式在健康服务系统改革与优化中的重要性。然而，在我国县域连续性服务实施过程中，仍面临过度关注医疗领域（范围的局限性）、“医—防、基层—医院”衔接机制缺失（路径的局限性）、忽视需方作用（主体的局限性）等挑战，导致割裂问题依旧严重。因此，本研究拟以服务为主线，从供需均衡视角剖析连续性服务的实现机制与优化策略：首先，基于慢病轨迹，构建连续性服务链，并从轨迹对比分析与连续性综合指数测算两个方面完成服务连续性现状评估；其次，从个体层面的供需匹配、机构层面的资源均衡、系统层面的供需交互演化三个维度剖析连续性服务实现的关键要素与核心路径；最后，依据LCES引导过程框架提出慢病连续性服务的优化策略。本研究既能够提升健康服务价值，亦可为县域分级诊疗制度完善、健康中国战略实现提供参考依据。

As a serious challenge to national health in the new era, chronic disease prevention and control has the characteristics of "long-term, multiple, and multi-agency" utilization, which further highlights the importance of collaborative and integrated care delivery model in the reform and optimization of health care system. However, in the process of continuous care implementation at county level in China, there are still challenges such as excessive attention to the medical field (limitation of scope), lack of connection mechanism of "treatment-prevention, primary health institution-hospital" (limitation of path), and neglect of the role of the patient (limitation of subject), which lead to serious service fragmentation. Therefore, this research intends to focus on service process，analyze the realization mechanism and optimization strategy of continuous care from the perspective of supply and demand equilibrium: first, build a continuous care chain based on the trajectory of chronic diseases, and complete the assessment of the care continuity’s current status from two aspects: trajectory comparative analysis and continuity comprehensive index calculation; second, the key elements and core paths of continuous care realization are analyzed from three dimensions: supply and demand matching at the individual level, resource balance at the organization level, and supply and demand interaction at the system level; finally, according to the LCES guidance process framework, the optimization strategy of chronic disease continuous care is proposed. This research can not only improve the value of health services, but also provide a reference for the optimization of hierarchical medical system at the county level and the realization of the healthy China strategy.