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Primary Care Medical Home Model

Other estimated about CNY 0

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Description

A comprehensive, coordinated primary care approach where patients establish ongoing relationships with a personal physician for preventive, acute, and chronic care management.

Main Uses

Primary purposes include: (1) Strengthening continuity of primary care through longitudinal patient–provider relationships; (2) Enabling proactive chronic disease prevention and management (especially for hypertension, type 2 diabetes, COPD, and elderly frailty); (3) Reducing avoidable hospital admissions and specialist referrals via early detection and coordinated care; (4) Standardizing essential public health services (vaccination, maternal/child health, geriatric assessments) at community level; (5) Supporting national health reform goals—e.g., tiered diagnosis & treatment, health insurance gatekeeping, and value-based payment models.

Normal Range

The 'Family Doctor Contracted Service Package (Basic Edition)' is not a laboratory or diagnostic test with numerical biomarkers; it is a comprehensive primary healthcare service model in China. It includes no quantifiable 'normal range' — rather, it defines standard service components: at least 1 annual physical examination (with specified items such as BP, BMI, fasting glucose, lipid profile, liver/kidney function, urinalysis, ECG, and age/gender-appropriate cancer screening), 4+ face-to-face or telehealth follow-ups per year, chronic disease management (e.g., hypertension/diabetes), health档案 establishment, prescription referral support, and 24/7 basic consultation access. Quantitative normal ranges apply only to the embedded clinical tests (e.g., BP <120/80 mmHg, FPG 3.9–6.1 mmol/L, LDL-C <3.4 mmol/L), not the service package itself.

Low Values - Possible Causes

Low utilization or incomplete delivery of the package may result from: (1) Patient non-adherence (e.g., missed appointments, refusal of screenings); (2) Primary care facility resource constraints (staff shortage, equipment gaps); (3) Inadequate digital infrastructure limiting remote monitoring and record integration; (4) Insufficient health literacy leading to underappreciation of preventive services; (5) Geographic or mobility barriers preventing access to contracted clinics.

High Values - Possible Causes

Apparent 'high' service intensity—beyond standard package scope—may occur due to: (1) Clinical necessity escalation (e.g., uncontrolled hypertension requiring monthly visits instead of quarterly); (2) Comorbid complexity (e.g., diabetes + CKD + depression triggering additional mental health and nephrology coordination); (3) Policy-driven expansion (local governments adding free influenza vaccination or bone density scans); (4) Patient-initiated demand for enhanced access (e.g., extended teleconsultation hours); (5) Quality assurance over-delivery (e.g., redundant lab repeats due to fragmented EHR systems).

primary care service health contract program preventive health package

estimated about CNY 0