Seven rules and regulations for chronic disease management

There is a lifelong responsibility system for first-diagnosis registration, quarterly screening system for high-risk groups, one-to-one doctor-patient follow-up contract system, interdisciplinary joint medication review system, lifestyle intervention points exchange system, annual early warning assessment system for complications, and door-to-door consultation system for disabled patients with chronic diseases.

When it comes to filing, we have to mention a big pitfall we stepped into in the early years: In 2019, Uncle Zhang, who had been suffering from diabetes for 12 years, came to our center to prescribe hypoglycemic drugs. The new doctor who treated him did not check his past medical history, and prescribed a foot soak prescription for warming the meridians and activating blood circulation as an ordinary patient, which almost caused the ulcer of his diabetic foot, which had already developed early lesions. After that, we finalized the lifelong responsibility system for the first consultation file. The medical team that receives the patient for the first time in the institution will be responsible for the dynamic update of this file for life, including the medical records of other hospitals, medication adjustments, and allergy history. Even if the patient transfers to other jurisdictions, we will synchronize the encrypted files to the connected social welfare. Of course, when this system was first introduced, many colleagues opposed it, saying that doctors have high turnover. If the entire team leaves, who will be held responsible? Our current solution is to add "double backup" to each file. In addition to the responsibility team, the agency's public health specialist must also review the file every six months to avoid files being lost.

It's useless to just rely on doctors to keep an eye on the patient. If the patient's own living habits don't change, any medicine will be of no use. This is also the original intention of our lifestyle intervention points exchange system. There used to be a 70-year-old Aunt Zhang whose blood pressure was still hovering at 160/100mmHg after taking antihypertensive drugs for three years. After careful questioning, I found out that she couldn't live without pickles, and her daily salt intake was at least 12 grams. After we launched the points system, she clocked in at home to limit salt and walked 6,000 steps every day. When her blood pressure reached the standard during follow-up visits, she could earn points, which could be exchanged for cooking oil, free physical examination coupons, and baduanjin classes. In just half a year, her blood pressure stabilized at 130/80mmHg. Of course, many experts in the industry question this model as a "short-term inducement." We have tracked the data for two years and indeed found that 15% of patients returned to their original lifestyle habits after redeeming the prizes. So this year we added a patient mutual aid group mechanism. In addition to exchanging points for physical goods, they can also be redeemed for free physical examinations for family members and priority participation in community health and wellness activities, slowly transforming external incentives into internal motivations.

More advanced than filing is the screening of high-risk groups. Previously, we followed the requirements of our superiors and followed the standard of screening once a year. It was not until we reviewed the follow-up data in 2019 that we were shocked: 30% of prehypertensive patients had confirmed hypertension after being screened one year later, and several people had already suffered early target organ damage. Later, we adjusted the frequency of screening for high-risk groups to quarterly. In addition to routine blood pressure and blood sugar tests, we also added free homocysteine ​​testing. In order to save manpower, we directly set up screening points at eight chain pharmacies in the jurisdiction, so residents can get tested while shopping for groceries. Of course, some colleagues in the public health system say that this model is too costly. We have calculated that screening a high-risk patient in advance can save at least tens of thousands of complication treatment costs a year. It is cost-effective no matter how you calculate it.

As for the interdisciplinary joint medication review system, it was completely forced by the miscellaneous prescriptions in the hands of patients with chronic diseases. Last year, a 78-year-old man came to see a doctor. He took out 5 prescriptions from his pocket, which were prescribed by the Department of Cardiology, Endocrinology, and Nephrology in different hospitals. There were a total of 8 kinds of medicine. After taking it for half a month, his feet were so swollen that he couldn't wear shoes. Our clinical pharmacist took a look and found that two drugs had duplicate ingredients, and the combination of two drugs would increase the risk of lower limb edema. After adjusting the medication, the edema disappeared within a week. Now we have established a rule: as long as patients with chronic diseases take more than three kinds of medicine at the same time, they must be reviewed by clinical pharmacists and general practitioners to confirm that there are no drug interactions or repeated use of medicines before the medicines are issued. There are also specialist doctors from large hospitals who feel that this process is unnecessary and say that they have already considered compatibility when prescribing. However, too many patients we contact at the grassroots level are treated across hospitals and no one is in charge of medication. One year after this system was implemented, the rate of adverse drug reactions among chronic disease patients in our jurisdiction dropped by 42%. The real results are here.

It’s funny to say that the one-on-one follow-up contract system between doctors and patients was forced by patients who blocked their phone calls. At first, we followed the unified requirement that all patients with chronic diseases need to be followed up by phone once a month. As a result, many patients with stable conditions found it annoying and directly blocked the social welfare phone number, and the follow-up answer rate was only 38%. Later, we simply gave the follow-up authority to the contracted doctors: newly diagnosed patients were followed up once a week for the first three months, and once every six months after their condition was stable for more than a year. For complications, the frequency was adjusted according to the risk level. The assessment was also changed from "number of follow-up visits" to "patient blood pressure and blood glucose compliance rate." After the adjustment, the follow-up call rate rose directly to 87%. Of course, some colleagues in management positions say that this model is too flexible and difficult to assess. In fact, as long as the core of assessment is changed from "completing tasks" to "benefiting patients", the problem will naturally be solved.

We have also implemented a "health traffic light" for each patient with chronic diseases, which is an annual early warning assessment system for complications: patients with diabetes will have their fundus and urine microalbumin checked every year free of charge, and patients with hypertension will have their carotid artery color ultrasound and kidney function checked every year. The final assessment report is made into a red, yellow and green card. For red high-risk patients, we directly help patients make an appointment with the specialist number of the superior hospital. For yellow, medium-risk patients, the indicators are tracked every 3 months, and for green, low-risk patients, normal follow-up is enough. Last year, we relied on this system to screen out 12 patients with early-stage diabetic nephropathy. Because they were discovered early, they did not develop to the point of requiring dialysis. Of course, there are also voices saying that this is excessive medical treatment. All of our screening projects are mandatory tests for chronic diseases clearly recommended by evidence-based medicine. They are all free and completely voluntary. There is no excessive problem at all.

The last system for door-to-door consultation for disabled patients with chronic diseases was only launched in our entire jurisdiction last year. There is an 82-year-old Grandma Li in the jurisdiction. She is paralyzed in bed due to the sequelae of cerebral infarction. Before, her two sons had to carry her downstairs to the hospital every time her blood pressure was measured and her urinary catheter was changed. The whole family was exhausted after such an ordeal. Now we are cooperating with the nursing home in the area. We visit her every month to test her blood sugar, adjust her medicine, change her urinary catheter, and teach her family members nursing skills. Most of the elderly's problems can be solved without leaving the house. The biggest bottleneck of this system currently is the lack of manpower. We are now trying to hand over basic vital sign detection to trained nursing staff. Doctors and nurses are responsible for visiting the home to provide medication adjustments and nursing guidance. The efficiency has more than doubled compared to before.

In fact, these seven systems are not a universal formula. Counties with vast territories and sparsely populated areas will definitely not be able to copy the quarterly screening requirements in urban areas. Communities with many young people can even exchange gifts redeemed by points for video memberships and fitness cards. The core is never a rigid system, but to really think about the problem from the patient's perspective and not make chronic disease management a task to cope with assessments, so that we can really help these people who need long-term care.