Chronic disease management work content and management plan

The core of chronic disease management is full-cycle health intervention for chronic non-communicable diseases such as hypertension, diabetes, COPD, and cardiovascular and cerebrovascular diseases. The core implementation modules can be summarized into five categories: basic monitoring, risk stratification, personalized intervention, long-term follow-up, and data review. Currently, the mainstream domestic implementation paths include community grid management, Internet + chronic disease management, and integrated medical and prevention management. There is no universal optimal solution. Matching the characteristics of the service population and matching the supply of local medical resources are the core standards.

In the past two years, I followed the public health research team to visit primary medical care points in 17 provinces and cities across the country. I have seen too many negative cases where chronic disease management has been reduced to "filling in forms to cope with assessments". I have also encountered many unsophisticated methods that managed to achieve high-standard samples. To be honest, this matter has never been as regular as written in the book.

Many people's first impression of chronic disease management is that community nurses squat at the door to measure blood pressure and fill in health records for uncles and aunts. This is both true and false. Practitioners in the public health system often regard "population coverage" as the first indicator. They feel that all chronic disease patients in the jurisdiction must be registered. If one is missed, the work is not done properly. ； However, most doctors on the clinical side do not agree with this logic. They feel that if the control is not up to standard, it means that there is no control. The key point is to focus on the incidence of complications and the blood pressure and blood sugar standard compliance rate. Otherwise, it will be useless to pile up a cabinet of files. ； People who build Internet chronic disease platforms have another idea: user compliance is the core. As long as patients can remember to take medicine and measure indicators regularly, whether it is using smart devices to remind or send push notifications, it will be more efficient than people watching. There is no right or wrong in these three types of views, they just have different standpoints. To do things well, you have to combine the needs of the three dimensions.

Let’s talk about the most basic monitoring process. I met an old man at a community health service center in Shandong last year. Every time he came to the center to measure his blood pressure, his blood pressure soared to 160/100. When I measured it at home, it was 130/80. At first, everyone thought that the blood pressure monitor at his home was broken, but they later found out when they came to the door. He walked 20 minutes every time he came to the center. He would roll up his sleeves to wipe off his sweat and take the test without resting at all. Later, the center simply set up a row of folding chairs at the monitoring point and posted a crooked handwritten reminder: "Sit for 5 minutes before taking the test. Don't be in a hurry." Later, similar misdiagnosis of "pseudohypertension" was reduced by 70%. These details will not appear in the official work manual at all. They are all the experience gained by front-line people.

The next step is risk stratification, which is a practice with relatively high industry consensus. For example, hypertension will be divided into four levels: low risk, medium risk, high risk, and very high risk based on risk factors and target organ damage. The frequency of follow-up and the intensity of intervention are different at different levels. Some scholars have opposed stratification in the past few years, thinking that all resources will be allocated to high-risk patients, and low-risk patients will easily become high-risk if no one cares about them. But in practice, you will know that a community usually has 2-3 chronic disease specialists who have to manage thousands of chronic disease patients, and it is impossible to take care of them without stratification. Low-risk patients are followed up once a quarter, and they are reminded to eat less salt and exercise more. High-risk patients who have just been discharged need to visit once a week for fear of accidents, so that resources can be used wisely.

As for personalized intervention and follow-up, it is more flexible. The medicine boxes for the elderly living alone should be labeled with large fonts. There is no need to preach too much to the young hypertensive patients. Just tell them "drink less milk tea and stay up late, otherwise you will have a stroke at the age of 30", but he will listen. Last time I met a community-based "peer support group" in Hangzhou, which invited diabetic patients with good blood sugar control to serve as volunteers, and told other patients how to control their sugar. It was more effective than what doctors had told them ten times. Everyone was a fellow patient, and what they said was down-to-earth and trustworthy.

Nowadays, the three most discussed management solutions have their own applicable scenarios and problems.

The most popular one is community grid management, which divides the jurisdiction into grids, assigns specialists to each grid, and goes door-to-door to arrange follow-up visits. For example, Aunt Zhang, who I met before, has been suffering from high blood pressure for 12 years and always forgets to take her medicine. The specialists come to her home every week to measure her blood pressure, and also help her put the medicine in a separate medicine box for morning, noon and evening, and post it for her grandson. After drawing cartoon stickers, her blood pressure stabilized and she took the initiative to volunteer. The advantage of this model is a strong sense of trust, which is especially suitable for communities with a large elderly population. The disadvantage is that there are not enough manpower. It is really difficult for a dedicated officer to manage hundreds of households. It is really difficult to do everything in detail. In many places, it ends up filling out forms to complete assessments.

The most popular thing in recent years is Internet + chronic disease management. Smart blood pressure monitors, automatic synchronization of blood sugar data, and online prescriptions and home delivery of medicines are especially suitable for young chronic disease patients in big cities who are unwilling to go to the hospital. I know a 32-year-old programmer who has high blood pressure for 3 years. But the problems with this model are also obvious. Many elderly people do not know how to use smart phones, and many people find it troublesome to wear the devices and throw them away in a drawer after using them for two days. Previously, a local government spent millions to purchase smart devices, but the final usage rate was less than 10%, and they were all piled up in the warehouse to gather dust.

On the policy side, the current main push is the integrated model of medical and prevention, in which specialists from large hospitals team up with public health teams in the community. The specialists are responsible for dispensing medicines and determining diagnosis and treatment plans, while community doctors are responsible for daily follow-up and health intervention. This is equivalent to opening up the treatment side of the hospital and the prevention side of the community. This model can significantly reduce the slowdown of the disease. The hospitalization rate of patients and the incidence of diabetes complications in many pilot areas have dropped by more than 30%. However, the resistance to implementation is not small - specialists in large hospitals have to see dozens of patients a day and cannot spare time for follow-up. In many places, it has become a formality to put up a sign and has no practical effect.

I have run so many pilot projects, and my biggest feeling is not to use any "national unified template", but the one that suits you is the best. Last time I saw a "chronic disease points system" implemented in a county in northern Jiangsu. Patients can earn points when they come to have their blood pressure measured, attend health lectures, and take medicine on time. The points can be exchanged for eggs, washing powder, and free physical examination places. Many elderly people deliberately take a detour in the morning to come to the community to have their blood pressure measured, and the compliance rate goes up all of a sudden. Do you think this method is crude? But their hypertension compliance rate is higher than many big cities that develop smart devices.

Oh, by the way, another point that is easily overlooked is the participation of family members. There used to be a diabetic old man who couldn't control his mouth and always secretly ate candied fruits. The doctor said it to no avail. Later, he invited his wife to a follow-up group. Every time he cooked, he was reminded to use less sugar and not to buy candied fruits when going for a walk. Within two months, his glycated hemoglobin dropped by 1.2 percentage points, which was more effective than any medication.

To put it bluntly, chronic disease management is never about piles of numbers and files, but about each and every living person. Don’t engage in professional preaching from above, and don’t blindly follow the trend and make airs. Follow the habits of the service recipients. If you can stabilize the indicators and reduce complications, it is a good plan.