研究背景和目的：构建适合的癌症生存者社区健康管理服务模式是当前完善我国卫生服务体系的突出需要。原因包括三个方面：第一，癌症发病率的提高和预后的改善使癌症生存者的数量不断增加，癌症生存者的医疗卫生需求也不断增加；第二，针对癌症生存者的医疗卫生需求，国家明确提出了“从诊疗到康复、从医院到社区的肿瘤全过程管理”的目标，但癌症生存者社区健康管理服务的相关政策还有待完善；第三，社区卫生服务因具有可及性、综合性、协调性、连续性和负责性的特点，能弥补专科服务的不足，满足院外癌症生存者的多种医疗卫生需求。然而，目前为我国院外癌症生存者提供后续医疗卫生服务的主要是医院专科，社区卫生服务机构很少参与其中，更缺少可参考的癌症社区生存者健康管理服务模式。因此，本研究在国家提出“肿瘤全过程管理”的背景下，以癌症生存者需求为导向，以社区卫生服务机构为癌症生存者提供服务的能力和潜力为基础，在管理协同理论的指导下，基于来自北京市的经验材料，进行了探索性研究，构建了具有操作意义的癌症生存者社区健康管理服务模式，期望能为癌症生存者的健康管理和分级诊疗的理论、实践和政策制定提供有价值的参考。

研究方法：本研究结合了定量与定性的研究方法，开展了癌症生存者需求的评估、社区卫生服务机构为癌症生存者提供服务的能力和潜力的评估，以及构建癌症生存者社区健康管理服务模式三部分的研究：（1）癌症生存者需求的评估部分，采用问卷调查与关键知情人访谈相结合的方式进行：问卷调查部分应用了汉化的癌症生存者未满足需求评估问卷（Cancer Survivors’ Unmet Needs, CaSUN），对在北京市某肿瘤专科医院招募到的324位癌症生存者的需求进行评估和分析；关键知情人访谈通过电话以半结构化访谈的形式进行，通过目的抽样招募了19位癌症生存者，本人和/或其家属参与了访谈。（2）社区卫生服务机构为癌症生存者提供服务的能力和潜力评估部分，采用焦点小组访谈和个人深入访谈相结合的方式进行：20位访谈对象中，3位专科医生和6位社区医务人员参与了两组焦点小组访谈，3位专科医生、7位社区医务人员和1位国家卫健委官员参与了个人深入访谈，针对社区卫生服务机构目前能为癌症生存者提供的服务，以及未来可能提供的服务发表了见解。（3）最后构建癌症生存者社区健康管理服务模式：根据癌症生存者需求和社区卫生服务能力与潜力的评估结果，以及对国内外文献的分析，在管理协同理论的指导下初步构建了癌症生存者社区健康管理服务模式，并邀请21位富有经验的癌症专科医生和社区医务人员作为专家对该模式进行两轮评价，以对该模式进行优化。

研究结果：（1）癌症生存者未满足需求评估问卷中，“信息需求和医疗问题”部分各项目反馈需求未被满足的比例最高，平均为55.69%，“生活质量”、“情感和人际关系问题”以及“生活视角”三部分各项目反馈需求未被满足的比例平均分别为32.44%，30.65%和27.07%。结合问卷调查和访谈结果发现，癌症生存者对沟通充分、协调统一、方便可及的医疗卫生服务的需求很强烈，并需要容易理解的医疗信息。在心理方面，最主要的是缓解担心癌症复发的需求；症状对情绪有很大影响，而家庭支持可以缓解心理情绪上的压力。癌症生存者对社会支持反映的未满足需求相对更低。病程长、参保新农合的癌症生存者在生理健康、情绪心理和社会支持各方面反映需求未被满足的比例都更低。（2）社区卫生服务机构目前能为癌症生存者提供基础检查，开具社区已配备的常用药物，进行简单的对症治疗，但服务范围受到资源配置和人员能力的限制；在健康管理、随访服务、转诊服务等方面的工作也是基于癌症生存者已有的常见慢性病进行，针对癌症本身的工作很少开展。专科医生认为社区卫生服务机构可以拓展业务范围，在能力允许的范围内开展更多癌症相关的诊断和治疗项目。（3）根据前期癌症生存者需求评估结果和社区卫生服务机构提供服务的能力和潜力的研究结果，参考对国内外文献的分析，本研究构建了包括 “政策和社会资源支持”、“社区医务人员培训”、“医院向社区转诊的必备条件”以及“社区提供的健康管理服务内容”四部分的癌症生存者社区健康管理服务模式，并包含下属16个二级项目和89个三级项目。两轮专家评价后，保留了“政策制度”、“社区医务人员培训”、“医院向社区转诊的必备条件”以及“社区提供的健康管理服务内容”四个部分，以及下属20个二级项目和65个三级项目。

研究结论：在评估了癌症生存者的需求和社区卫生服务机构为癌症生存者提供服务的能力和潜力的基础上，本研究在管理协同理论的指导下，经过专家评价，构建了针对癌症生存者的社区健康管理服务模式。该模式以“政策制度”为服务首要前提，以“社区医务人员培训”奠定服务能力基础，以“医院向社区转诊的必备条件”和“社区提供的健康管理服务内容”为服务基本内容，包含了在政策制度上的需求，肿瘤专科医生和社区全科医生的分工，转诊和接诊过程中专科医生和全科医生需要向癌症生存者和合作医务人员提供的信息等等。该模式强调，社区卫生服务机构可以发挥社区卫生服务连续性、可及性等优势，让癌症生存者享受到连续全程的健康管理服务。但还需要提升癌症生存者的主观能动性，社区卫生服务机构需要进一步地加强人才、资源和能力的建设，医院和社区需要加强各方面的合作与资源共享，政策上需要明确有力的支持，要在更多地区开展癌症生存者社区健康管理服务的研究与实践，才能更好地推动癌症生存者社区健康管理服务的落实。

Background and purposes: A suitable community health management service model for cancer survivors is an outstanding need for our health service system. The reasons include three aspects: First, increasing incidence and improving prognosis of cancer are contributing to the increasing number of cancer survivors, as well as their medical needs. Second, the whole process management goal of “from diagnosis to rehabilitation, from hospital to community” rised by National Health Commission (NHC) can met the growing health care needs of cancer survivors, but the relevant policies of community health management need to be improved. Third, the accessibility, comprehensiveness and coordination of community health services can meet the deficiencies of specialized treatment and the various medical and health needs of cancer survivors. However, cancer survivors in China are mostly followed up and treated by oncologists, community health professionals rarely participate in their health service, and there is still a lack of a suitable model for community health management for cancer survivors. Therefore, this study developed a community health management model for cancer survivors on the basis of cancer survivors’ needs and present capabilities and possible potential of community health service, so as to provide reference for the hierarchical diagnosis and management of cancer in the future.

Methods: This study combined quantitative and qualitative methods to carry out three parts of researches: need assessment of cancer survivors, capacity and potential assessment of community health service, and developing community health management model for cancer survivors. (1) Firstly, questionnaire surveys and interviews were conducted to assess the needs of cancer survivors. Cancer Survivors’ Unmet Needs (CaSUN) assessment questionnaire was used to investigate the needs of 324 cancer survivors in a cancer hospital in Beijing. We also had 19 interviews on the needs of 19 cancer survivors, cancer survivors themselves and/or their family members were interviewd.  (2) Secondly, focus group interviews and in-depth personal interviews were conducted in oncologists, community health professionals and officers to detect the current status and potential ability of community health services on cancer survivors. Of the 20 people interviewed, 3 oncologists and 6 community health professionals participated in 2 focus group interviews, 3 oncologists, 7 community health professionals and one NHC officer were personally interviewed. (3) Finally, on the basis of the cancer survivors’ need assessment and the research on community health service capacity and potential, a community health management model for cancer survivors was initially constructed. A total of 21 oncologists and community health professionals were invited as experts to optimize the service model.

Results: (1) In the questionnaire survey of cancer survivors’ unmet needs, “information and medical care issues” had the highest average percentage of unmet needs at 55.69%. The average proportion of unmet needs on “quality of life”, “emotional and relationship issues” and “life perspective” were 32.44%, 30.65% and 27.07% respectively.  Based on the results of questionnaire survey and interviews, it was found that cancer survivors had strong needs for well-communicated, coordinated and convenient health services, as well as comprehensible medical information. The most important psychological issue was to relieve the worries on recurrence. Symptoms had a great impact on emotions, and family support could relieve the pressure. Needs for social support were relatively lower. Cancer survivors with a longer history and who participated in the New Rural Cooperative Medical Care System reported lower rates of unmet needs in physical, psychological and social support.  (2) Community health service centers could provide basic physical tests and auxiliary inspections, commonly used drugs and simple symptomatic treatment for cancer survivors, but the services were limited by current medical resources. Services like health management, follow-up, referral, etc. were also provided if cancer survivors had any common chronic disease, but little work focused on cancer itself. Oncologists believed that community health services could expand to cancer screening and examinations, and could prescribe safe, long-term and repeated anticancer drugs for cancer survivors under the guidance of oncologists in the future.  (3) The initial service model included four parts: “policy and social resources”, “training of community health professionals”, “hospital-to-community referral plan” and “community reception and management”, as well as 16 secondary and 89 tertiary items. After two rounds of consultations, the four parts “policy and rules”, “training of community health professionals”, “hospital-to-community referral plan” and “community reception and management” were retained, as well as 20 secondary and 65 tertiary items.

Conclusion: Based on the cancer survivors’ need assessment and the community health services can be provided for cancer survivors, a community health service model for cancer survivors was established: Cancer survivors had higher physical needs than psychological or social needs. The key needs were communicatable, coordinate and accessible health services, as well as understandable medical information. Cancer survivors’ expectation and need on community health services were not high. Community health service institutions only had basic equipment and drugs, and community medical worker could only provide basic diagnosis, treatment, nursing, follow-up and other services for cancer survivors. In the absence of a clear policy system to promote the work on cancer survivors, the community medical workers lack the knowledge and skills of cancer prevention and treatment, and they had less motivation to provide services to cancer survivors. After identifed the gaps between the cancer survivors and service providers, as well as the possible cooperation between hospitals and community health service institutions, a four-part community health management model with “policy and rules”, “training of community health professionals”, “hospital-to-community referral plan” and “community reception and management” for cancer survivors was established. Continued and accessible community health service can can meet the cancer survivors’ needs. Furthermore, to better meet the cancer survivors’ needs, cancer survivors need to be more motivated, community health service institutions need to cooperate with hospitals closely to exchange resources and strengthen the community medical personnel, and clear policies should be introduced powerfully.