What is the core of chronic disease management?

The core of chronic disease management has never been to manage the disease, but to manage the person - that is, to provide continuous intervention support adapted to the patient's actual life based on the patient's full-cycle health needs, rather than focusing on the numerical card standards on the test sheet, or making up enough follow-up visits to meet the assessment.

In the early years, there were indeed different views in the industry. Many people felt that the core was the "indicator compliance rate". After all, the assessment was strict. The blood pressure dropped below 140/90 and the fasting blood sugar reached 6.1mmol/L to be considered qualified. The actual situation of the patient was not taken into account at all. Our center previously received a 72-year-old man with 12 years of diabetes and Parkinson's disease. His hands sometimes shook. In order to increase the compliance rate, the previous doctor gave him two oral hypoglycemic drugs. His blood sugar did drop to 5.8. However, the old man fainted twice in a row. Once when he went downstairs to buy groceries, he fell and lay down for two months with a fractured femoral neck, which was a serious crime. Later, we re-evaluated him, relaxed his blood sugar control target to 7.5-8.5, changed him to a milder blood sugar-lowering plan, and asked the community nurse to come to his home every week to teach him how to play a simplified version of Baduanjin, and taught his wife how to prepare multi-grain rice with a low glycemic index. Now his glycated hemoglobin has been stable at around 7.1. Not only has he not suffered from hypoglycemia again, he can go to the park for half an hour every day and dig in the sand with his granddaughter. His condition is much better than before.

Some people also think that the core of chronic disease management is "improving patient compliance." To put it bluntly, it means asking patients to listen to the doctor and take medicines and follow up for follow-up appointments on time. This sounds right, but when it comes to practice, you will know how difficult it is. Last year, we found a 38-year-old hypertensive online ride-hailing driver who was overweight. He had been prescribed short-acting antihypertensive drugs three times a day. Every time he followed up, he said he had forgotten to take them, and his blood pressure had been hovering at 160/100 for three months. Later, we chatted with him for two hours and found out that he was running orders for 14 to 5 hours a day, and even took a few bites of food while waiting for orders. How could he have time to take medicine at a scheduled time? Later, he was switched to a long-acting antihypertensive drug that he takes once a day, and he was specifically told to take the medicine every morning when he went out to touch the car keys. The medicine was placed directly in the key box. When he was tested again the next month, his blood pressure dropped to 138/86. He said, "I will never forget it again this time."

In fact, to put it bluntly, chronic disease management is like custom-making shoes that are often worn by a person. It is not about trying to fit a person's feet with a national standard code. You must first know the size of his feet, whether he has collapsed arches, whether he walks a lot or sits for a long time, whether he likes to wear sports shoes or leather shoes. Nowadays, we often see various new chronic disease management tools, such as smart monitoring bracelets and automatic follow-up systems. To put it bluntly, they are all auxiliary tools. If we forget that the core is to follow the needs of patients, no matter how high-end the tools are, they will be just frivolous. After all, chronic diseases follow people throughout their lives. You have to accompany the patient to find the most suitable way for him to coexist peacefully with the chronic disease. This is the real implementation of management.