How to carry out chronic disease management

The core of chronic disease management has never been to keep tabs on the patient's blood pressure, blood sugar and other indicators, but to build a coherent service chain of "in-hospital diagnosis and treatment - out-of-hospital follow-up - home support" around the patient's life needs in all scenarios. The essence is to "manage people" rather than "manage indicators".

I have been working in chronic disease management services at the grassroots level for 4 years, and I have encountered many pitfalls. At first, I copied the standardized template given by my superiors, and made regular calls every week to urge patients to measure indicators and upload data. At the end of the month, the statistical compliance rate was less than 27%. Many elderly people answered the phone and just said a few words, turning around whether they should eat pickles or eat. Later, I followed the team to conduct a pilot project in the streets. I spent a month going door-to-door to find out the situation. I even recorded the detailed information in the ledger, including which gout patients liked to drink Laohuo soup, which elderly people lived alone and no one reminded them to take medicine, and which young people who were busy at work and always forgot to prescribe antihypertensive medicine. I slowly figured out the way. Last year we served a 71-year-old COPD patient, Uncle Wang, who had been well treated in the hospital, but his cough kept recurring when he returned home. After visiting him, we found out that he was reluctant to turn on the air conditioner and kept the windows open in the summer. Kapok wadding grown by neighbors downstairs drifted in, which could easily induce coughing and wheezing. Instead of asking him to turn on the air conditioner, we coordinated with community volunteers to install dense-hole screens for his windows, and contacted a respiratory doctor to adjust the time for him to use inhalers. After that, his number of relapses dropped by 80%.

There are actually many differences in the development path of chronic disease management in the industry. Some experts advocate relying on digital tools to improve efficiency, promoting intelligent monitoring equipment and online health education, which can expand the service radius and reduce costs. We have also provided smart blood pressure monitors to young chronic disease patients aged 30 to 50 in our jurisdiction. Data Automatically synchronize to the background, and call for follow-up if there is an abnormality. The efficiency has indeed improved a lot. However, most of the devices issued to the elderly over 65 years old either cannot connect to Bluetooth or forget to take them when they go out. In the end, they still have to rely on the community medical care team to come to the door every week. Neither of these two models can replace the other, and they have to meet the needs of the population.

If you really want to put it into practice, just relying on a few doctors in the community hospital will definitely not be enough. We are now cooperating with the elderly care station on the street, the pharmacy downstairs in the community, and even the leader of the square dance team. During the square dance, the leader casually mentions, "There will be a free blood glucose testing event in the community tomorrow, please remember to go on an empty stomach." It is more effective than the 10 notices we posted. If you encounter an elderly person whose children are not around, the pharmacy can also help deliver medicine to the door, saving the elderly from traveling long distances. To be honest, chronic disease management is a bit like being a "health partner" for people. Don't always stand on the commanding heights of the profession and ask the patient not to eat or do this. You have to adjust the plan according to his living habits. For example, if the patient likes to eat soy sauce meat, don't directly say fasting. Calculate for him to eat one or two at a time, paired with half a pound of green leafy vegetables. If he can do it, it will be really useful. We have been doing this for so long, but we have never found any universal template that can make patients willing to cooperate, maintain stable indicators, and maintain quality of life. This is the most reliable way to carry out the treatment.