Chronic disease management work system content

Currently, the core framework of the chronic disease management work system implemented by medical institutions at all levels in China generally revolves around the four core service links of "screening and archiving - follow-up and intervention - hierarchical referral - effect evaluation", and supports four types of guarantee rules: personnel rights and responsibilities, quality control and assessment, information security, and patient rights and interests. There is no nationally unified fixed text, and each locality will make personalized adjustments based on the chronic disease onset characteristics and service capacity of the population under its jurisdiction.

I have worked in chronic disease management in grassroots social welfare for 6 years, and have seen no fewer than a dozen versions of the system. Social welfare systems in old urban areas where the elderly population accounts for more than 40% will specifically include mandatory monthly home visits for empty-nest and disabled elderly people with chronic diseases. The social welfare system next to the Internet Industrial Park, The service serves 70% of people aged 20-40, and the detection rate of high uric acid and dyslipidemia is higher than that of high blood pressure. The system will additionally require health promotions at the company at least once a month. Follow-up visits are prioritized through online mini-programs and community reminders, and there is no need to limit the number of face-to-face follow-up visits.

To be honest, after so many years of system changes, there have always been two different schools of thought in the industry: Managers with public health backgrounds are more inclined to tighten indicators. Hard indicators such as standardized management rates and blood pressure and blood sugar control rates must be directly linked to funding allocations. After all, chronic disease management is part of basic public health services, and you will see results if you spend financial money.； Most front-line clinicians feel that they cannot rely solely on indicators. In the past few years, there have been cases of falsification of follow-up records for deceased chronic disease patients in order to make up for the number of follow-up visits. Instead, patients who really need services have been missed. In the past two years, many places have also made adjustments to include more tangible indicators such as patient satisfaction and complication rates.

The current system in our center clearly requires that those over 35 years old must have their blood pressure measured at the first visit, those over 40 years old have their fasting blood sugar tested for free at least once a year, and high-risk groups with a family history of chronic diseases and overweight people are screened every six months. Last year, we relied on this screening to identify Aunt Zhang, who danced square dances every day in the community. She was She felt that there was nothing wrong with her because she could eat and sleep. When her fasting blood sugar was measured at 7.3mmol/L, she was in the pre-diabetic stage. So she quickly set up a diet and exercise plan. Three months later, the reexamination dropped to 6.1. If there was no mandatory screening required by the system, she might have to take medication for life when she developed symptoms of more than one and less than three months.

The previous system required face-to-face follow-up visits once every quarter, which really worried us. Many elderly people went to Hainan to escape the cold in winter and stayed there for half a year. We couldn't fly there to see them for follow-up visits, right? The system has been changed in the past two years. Video follow-up and telephone follow-up can be regarded as effective follow-up as long as the identity is verified, blood pressure, blood sugar values, and medication status are clearly recorded. It is much more flexible, and our work pressure is much less. On the contrary, the true rate of follow-up has increased a lot.

Oh, yes, the terms of hierarchical referral give patients the strongest sense of gain. The system clarifies that patients with chronic diseases who develop complications and need to adjust their treatment plans can make an appointment with the chronic disease specialist number of the higher-level hospital within 72 hours after the social health department issues the referral order. There is no need to wait for the number yourself. Last year, there was a patient with diabetes 1 Two-year-old Zhou was found to have fundus infiltration. He received a referral on the same day and went to the ophthalmology department of the Municipal People's Hospital the next day. After the laser treatment, we followed up with follow-up blood sugar control and follow-up. The connection was particularly smooth. Lao Zhou said that if he had registered by himself before, he would have had to wait at least half a month.

As for the protection rules, they are actually the result of trial and error. The system of our center is very clear. Each general practitioner is bound to 800-1,000 patients with chronic diseases, which is equivalent to everyone having their own "responsibility field." When patients have problems, they can directly go to their own doctor. There will be no situation where no one knows anyone who calls. The assessment is no longer based on money deductions like before. Now it is a bonus point system. If the control rate of the patients you manage is higher than the average, or if there are patients who come specifically for praise, you can get extra subsidies, and everyone is more motivated. There is also a red line for information security. The system clearly requires that the health records of patients with chronic diseases can only be used for medical services and cannot be disclosed casually. Last time, a pharmaceutical company asked us for the contact information of patients with hypertension, but we refused directly. This is a bottom line that cannot be touched.

After working in chronic disease management for so many years, my biggest feeling is that this system has never been a decoration hanging on the wall. It has to be adjusted slowly according to the needs of patients. For example, many young people now have chronic diseases and find it troublesome to go to the social welfare system to get medicines. We have recently been changing the system and are preparing to launch a home delivery service for chronic disease medicines. As long as you follow up online and write a prescription, they can be sent directly to your home. Of course, there is still a lot of room for discussion. For example, whether the completion rate of lifestyle interventions such as smoking cessation and weight loss should be included in the mandatory assessment. Different places are still trying it. After all, chronic disease management itself is a slow effort, and the system must also be developed slowly. A good system is one that can truly help patients.