资源联动与制度协同：云南边疆慢性病连续服务实践研究

Resource Linkage and Institutional Coordination: A Practical Study on Continuous Chronic Disease Services in Yunnan Border Areas

To address the dilemma of continuous service disruption in chronic disease management in multi-ethnic border areas of Yunnan, this study, based on the Continuum of Care Theory, takes Honghe Prefecture and Dehong Prefecture as research contexts, adopts semi-structured interviews combined with secondary data analysis, and explores the synergistic logic of the medical consortium and family doctor contract system, the linkage paths between formal medical resources and informal social support, as well as their impacts on patients' service accessibility and quality of life. The research finds that medical consortia provide formal resource support for family doctors through measures such as green referral channels, and family doctors, by collaborating with ethnic community leaders and other stakeholders, embed informal support into the service process, forming a three-dimensional continuous service chain encompassing “relationship-information-service”. This chain improves patients' service accessibility and quality of life, verifying the adaptability of the Continuum of Care Theory in the context of multi-ethnic border areas. This study enriches the contextualized application of the theory and provides empirical reference for optimizing chronic disease management policies in border areas.

为破解云南边疆多民族地区慢性病连续服务“断链”困境，本研究基于连续照护理论，以红河州、德宏州为情境，用半结构化访谈法结合二手资料分析，探讨医共体与家庭医生签约制度协同逻辑、正式医疗资源与非正式社会支持联动路径及其对患者服务可及性与生活质量的影响。研究发现，医共体通过绿色转诊通道等举措为家庭医生提供正式资源支撑，家庭医生联动民族社区领袖等，将非正式支持嵌入服务流程，形成“关系- 信息- 服务”三维连续服务链。该链条提升了患者服务可及性与生活质量，验证了连续照护理论在边疆多民族情境的适配性。本研究丰富了该理论的情境化应用，为边疆地区优化慢性病管理政策等提供实证参考。