Chronic disease management refers to regular testing of chronic diseases and their risk factors; Continuous monitoring, Evaluation and comprehensive intervention management of medical behaviors and processes& zwnj; Its main connotations include early screening of chronic diseases; Risk prediction, Early warning and comprehensive intervention, And comprehensive management of chronic disease populations; Effect evaluation, etc& zwnj; The impact of chronic disease management on patients and society is profound; Therefore, its importance cannot be ignored& zwnj; Through active management, Can control the progression of diseases, Relieve symptoms, Prevent complications, Reduce medical expenses, Improve the quality of life& zwnj;
The methods of chronic disease management include biomedical monitoring; Medication and monitoring patients' adherence to medical orders, Simultaneously including psychological intervention and social environment intervention& zwnj; Psychological intervention changes patients' perception of diseases and subsequently their behavior through health education; And social environment intervention involves group work methods; Community work methods and policy evaluation methods, etc; To promote personal problem-solving and social change& zwnj;
In practical operation, The general practitioner team is responsible for the prevention and control of chronic diseases in the community; Establish resident health records, Implement graded follow-up management based on the severity of the disease& zwnj; For high-risk and diseased populations; Take proactive intervention and regular monitoring, To detect diseases early and control their progression& zwnj; The Chronic Disease Management Center of the hospital establishes electronic health records and; Classify and manage patients, Post discharge management, Data collection and analysis, The dissemination of health science popularization knowledge, And establish a chronic disease network both inside and outside the hospital, Realize the tracking and service of the entire health process of chronic disease population& zwnj;