【摘要】 在人口老龄化与慢性病负担加重的背景下，传统以单次诊疗和单一专科为主的医疗服务模式难以满足患者长期健康管理需求，服务碎片化与“出院即失访”问题日益凸显。本文基于连续性照护与整合型医疗卫生服务理论，系统梳理了国内外典型随访管理模式，分析了国内在推动患者全程随访管理中面临的制度与运行层面的主要瓶颈。在此基础上，围绕随访服务内容设计、运行标准构建以及筹资激励机制完善等方面提出相应政策建议，旨在推动患者全程随访管理由零散探索向制度化、规范化运行转变，为医疗机构构建高质量、可持续的整合型随访体系提供实践指南与政策参考。更多还原

【Abstract】 In the context of population aging and the increasing burden of chronic diseases,the traditional healthcare service model centered on single episodes of care and single specialties can no longer meet patients’ long-term health management needs.Issues such as fragmented services and loss to follow-up after discharge have become increasingly prominent.Based on the theories of continuity of care and integrated healthcare services,this study systematically reviews typical follow-up management models at home and abroad and analyzes the major institutional and operational bottlenecks in promoting full-process patient follow-up management in China.On this basis,policy recommendations are proposed in terms of follow-up service design,establishment of operational standards,and improvement of financing and incentive mechanisms.The study aims to promote the transition of patient follow-up management from fragmented exploration to institutionalized and standardized operation,providing practical guidance and policy references for healthcare institutions to build high-quality and sustainable integrated follow-up systems.更多还原