为了提高残疾人家庭医生签约服务质量，国家卫生健康委基层卫生司和中国残疾人联合会康复部于2018年8月联合出台《残疾人家庭医生签约服务指导手册》。通过调查合并慢性病的肢体残疾人，发现《手册》具体实施过程中的问题，为进一步修改《手册》提供依据。

于2019年8~12月，根据信息饱和原则，采用方便抽样法选取北京市西城区月坛社区卫生服务中心的12名合并慢性病的肢体残疾人作为研究对象，进行半结构化访谈。

根据残疾级别对受访者实行分层管理，66.7%（8/12）受访者在社区卫生中心签约，33.3%（4/12）受访者在残疾人家中签约；慢性病随访率、健康宣教率及体检率均为100%；41.7%（5/12）的受访者接受过合并症及并发症的诊治；康复治疗需求率为100%，满足率83.3%（10/12），16.7%（2/12）的受访者想转介到康复医院；75.0%（8/12）受访者有上门服务需求，实际满足率为37.5%（3/8）；所有受访者及家属均表示对护理知识有需求，25.0%（3/12）的受访者接受过社区护士的护理指导；所有受访者均反映，与残疾人专职委员联系少；4/12（33.3%）受访者提出康复设备陈旧，有更新康复设备的需求。

《手册》的实施增进了家庭医生与肢体残疾人之间的交流，对提高残疾人家医签约服务质量有一定的促进作用。受家医团队成员数量不足，胜任力有待提高等条件限制，部分上门服务、康复治疗及转介等服务内容还不能完全做到。《手册》可增加对工作人员及残疾人培训、康复医联体建立、上门服务的规范管理等相关内容。

In order to improve the quality of contracted family doctor services for persons with disabilities, the Department of Primary Health, the National Health Commission of the People's Republic of China, and the Rehabilitation Department of the China Disabled Persons' Federation jointly issued the Manual on Contracted Family Doctor Services for Persons with Disabilities (hereinafter referred to as the Manual) in August 2018. By investigating the physical disabled persons with chronic diseases, this sudy aimed to find out the problems in the implementation of the Manual and provide a basis for further modification of the Manual.

Semi-structured interviews were conducted from August to December 2019, Twelve physically disabled persons with chronic diseases in Yuetan Community Health Service Center, Beijing's Xicheng District were selected by convenient sampling method.

According to the level of disability, 66.7% (8/12) of the interviewees signed the contract in community health centers, and 33.3% (4/12) of the interviewees signed the contract in their home. The rates of chronic disease follow-up, health education, and physical examination were all 100%. Approximately 41.7% (5/12) of the interviewees had received treatment of concomitant diseases and complications. The demand rate of rehabilitation treatment was 100%, the satisfaction rate was 83.3% (10/12), and 16.7% (2/12) of the interviewees wanted to be referred to the rehabilitation hospital. About 75.0% (8/12) of the interviewees had door-to-door service demand, and the actual satisfaction rate was 37.5% (3/8). All the interviewees and their family members expressed that they had a need for nursing knowledge, and 25.0% (3/12) of the interviewees had received nursing guidance from community nurses. All interviewees expressed that they had little contact with the full-time members of the disabled committee, and 4/12 (33.3%) interviewees proposed that rehabilitation equipment was obsolete and needed to be updated.

The implementation of the Manual has promoted the communication between family doctors and physically disabled persons, and has played an appreciated role in improving the quality of contracted services of family doctors for the disabled. Limited by the insufficient number of family medical team members and the need to improve their competence, some services such as door-to-door service, rehabilitation treatment, and referral can not be fully achieved. Relevant contents such as training for staff and physically disabled, establishment of rehabilitation medical alliances, and standardized management of door-to-door services can be added to the Manual.