Personal work summary of chronic disease management

The standardized management rate increased from 62% at the beginning of the year to 87%, and the blood pressure and blood sugar control compliance rate increased from 58% to 79%. However, there are still 23 elderly patients whose medication compliance is less than 30%, and 11 migrant workers with chronic diseases are in a leaky/semi-leaky status. In addition, there is currently a conflict between the two management ideas of "emphasis on public health indicators" and "emphasis on patient experience" in the industry. I have not yet figured out a balanced plan that fully adapts to the situation in the jurisdiction.

Let me tell you something that just happened last week. The 68-year-old Aunt Zhang Guiying held my hand and stuffed it with two pieces of dried oranges that she had dried herself. She said that she had never suffered from dizziness in the past half month. She has been suffering from high blood pressure and hyperlipidemia for almost 10 years. She told me to take her medicine on time every time she followed up. As a result, last month’s free blood pressure test in the community soared to 180/100. After questioning her for a long time, she said she had secretly stopped irbesartan and replaced it with the “Vascular Scavenger” health product she bought at a community health lecture. She was told that she could stop taking the medicine in half a year. In the past, I might have started chanting the mantra "Don't buy health care products randomly". That time I didn't make any sense. I took a photo of the ingredients list of her health care products and looked at her prescription list one by one: it contains vitamins, cassia seeds and some dietary fiber. Wei, if you really want to lower your blood lipids and stabilize your blood pressure, you have to rely on the statins and antihypertensive drugs you take. I was afraid that she wouldn't believe it, so I called her niece who was an internal medicine nurse in the city hospital and called her. I made three trips and the blood pressure measured last week has stabilized at 135/82.

When I first started working in this field, I was actually a staunch "indicator" person. After all, there were hard and fast points in the public health assessment: whether the number of follow-up visits was sufficient, whether the files were completely filled out, whether there was any omission of medication records, and any item with points deducted would be criticized. At that time, in order to make up for the quarterly face-to-face follow-up, I would stand in front of the vegetable market at 7 o'clock in the morning, waiting for the elderly to buy groceries. I would make follow-up calls to patients who were working outside for ten minutes. I would continue to call after they hung up because they were annoyed. Later, a diabetic patient who drove an online ride-hailing company directly blocked me. I still felt aggrieved at that time. I thought I was doing it all for your own good. Why don't you appreciate it?

Later, I participated in a chronic disease management training in the province and found out that this matter is actually quite controversial in the industry. Experts who study the public health system believe that standards are the bottom line. If the number of follow-up visits and recording standards are not uniform, the chronic disease monitoring data will be inaccurate, and the entire grassroots prevention and control system will lose its reference significance. However, experts with clinical experience say that the core of chronic disease management is people, not indicators. Some elderly people have to send their grandchildren off in the morning and pick up their children in the afternoon. , if you have to follow up at your door during required working hours on working days, people will have no time to care about you. There are also some mobile workers who travel to several cities every month. It is impossible for you to follow up face to face. It is better to loosen the standards. Even if it is WeChat follow-up or telephone follow-up, as long as the patient can really take medicine on time and control his diet, it is worse than anything else.

I later tried to adjust the method. For example, I divided the follow-up time into two slots: 7 a.m. to 8 a.m. and 6 p.m. to 8 p.m., specifically for patients who have to go to work and take care of their children. For patients who work outside the home, I set up a small group and sent out some dietary advice to them every week, such as how to choose low-oil fast food for takeaways, how to find fragmented time for exercise for those who drive online taxis, and privately ask about blood sugar and blood pressure status once a month. During my physical examination at the end of the year, the online ride-hailing driver who blocked me before came to me specifically and said that he ordered food according to my suggestions. Now my fasting blood sugar is stable at around 6.2, which is much better than the previous high of 9 o'clock. He also brought me a bottle of ice mineral water, which made me feel warm at the time.

Of course, there are many troublesome things. The most troublesome thing is the problem of leaking tubes in mobile patients. In March this year, a 29-year-old takeaway boy came to the community to have his blood pressure measured and his blood pressure was found to be 155. I registered him and left a phone number at that time, but the number I called again in May was unavailable. It took me more than half a year to contact him through the website. He went to the hospital last month for dizziness and had a mild lacunar infarction. He said he had changed his mobile phone number and forgot to tell me. He always felt that he was young and high blood pressure was not a big deal. I felt so panicked when I heard this. Now, some in the industry are talking about linking chronic disease management data with takeout and online ride-hailing platforms, and some are talking about linking it with big data for disease control. However, when it comes to personal privacy, progress is very slow. Now I can only ask for WeChat every time I register mobile patients, and ask them to tell me if they change their numbers, but the effect is actually average.

In fact, I think chronic disease management is like regular maintenance of an old house. It doesn’t mean that you just go through the process and paint the exterior walls to look good. Invisible details such as leaking water pipes and loose wires are the most likely to cause problems. Some people have a dry cough after taking antihypertensive drugs. You can't force them to continue taking them. You have to help them contact the doctor to adjust the medicine. Some people just don't like vegetables, so you can't force them to eat every meal. You have to find alternative high-fiber recipes for them. After all, what we care about is not a series of cold indicators, but living people.

I don’t have any ambitious goals for next year. I will first get to know more about the conditions of the 200 patients in my care, such as whose medicines have side effects and whose family members have no one to help measure their blood sugar. I will try to slowly figure out a small method that does not violate the regulations and will make the patients willing to cooperate. Even if I can only help a dozen more people a year to stabilize their indicators, this year’s work has not been in vain.