What does chronic disease management include?

The essence of chronic disease management is to target chronic diseases such as hypertension, diabetes, COPD, and rheumatoid arthritis that have a long course, many complications, and complex causes. It covers a series of continuous and proactive health services from risk prevention, diagnosis and intervention to later recovery. It is not as simple as measuring blood pressure regularly and prescribing antihypertensive drugs as everyone thinks. To put it bluntly, it is like an exclusive health steward for people with chronic diseases and high-risk groups. Issues related to food, drink, housing and transportation, medical treatment and medication, and even medical insurance reimbursement, as long as they are related to the control of chronic diseases, are mostly covered.

The most cutting-edge risk screening is something that many people are unaware of. Nowadays, many communities provide free physical examinations for people over 65 years old every year, lung function screenings for people who smoke all year round, and blood sugar monitoring for overweight people. These are all the first steps in chronic disease management. They are to single out those who have not yet developed the disease but have high-risk factors, and provide advance advice on adjusting their diet and exercise. Of course, there are different opinions now. Some public health scholars believe that the cost of large-scale universal screening is too high, and the input-output ratio is not high for some chronic diseases with low incidence. There are also research data showing that targeted screening for high-risk groups can reduce the cost of treatment of later chronic diseases by more than 60%. At present, various regions in the country are also adjusting the scope of screening based on their own financial conditions. Economically prosperous areas will also include bone density and oral mucosal screening, while less developed areas should first focus on the prevention and control of high-incidence chronic diseases such as hypertension and diabetes.

Patients who are truly diagnosed with chronic diseases can enjoy even more detailed services. Aunt Zhang from our community has been diagnosed with type 2 diabetes for 5 years. In the past two years, she took medicine randomly, and her blood sugar fluctuated. Last year, she joined our chronic disease management group. We first created a dedicated health file for her. She clearly remembers her blood sugar level, medication status, and allergy history every time. There is no need to repeatedly ask about her past medical history when dispensing medicine. In addition to regular medication guidance, we will remind her to undergo fundus and kidney function complication screening every six months. Previously, she was diagnosed with early-stage diabetic retinopathy. Because it was discovered early, she only adjusted her medication and it was under control. If she waited until her eyes could not see clearly before going for a check-up, she would most likely need surgery.

Many people think that chronic disease management is all about medical treatment. In fact, lifestyle intervention accounts for almost half of it. Our community just held three sugar-control cooking classes last month, teaching everyone how to use low-sodium salt, how to use whole grains instead of polished rice and white flour, and how to eat fruits without raising blood sugar. After an uncle participated, his fasting blood sugar dropped from 7.8 to 6.9, without increasing the dosage of medicine. Psychological counseling is also very important. Many patients with chronic diseases take medicine all year round and are prone to low self-esteem and anxiety. We used to have an old man with COPD who felt that he was a burden on his children and was unwilling to leave the house. We found a volunteer who had also suffered from COPD for more than 10 years and talked to him three times and taught him breathing exercises. Now he takes the initiative to go downstairs for a walk every day and his condition is much better.

In the past two years, chronic disease management has also moved online. We now have an exclusive small program that allows patients to measure blood pressure and blood sugar at home and upload it directly. When we see abnormal values ​​in the background, we will proactively call to inquire about the situation, eliminating the need to constantly go to the hospital, which is very convenient. By the way, there are many policy connections that patients tend to overlook, and we will also help with them, such as the application for special diseases in chronic disease outpatient clinics and the adjustment of reimbursement ratios. Last month, an aunt didn't know that the chronic disease card could be renewed. After we reminded her, she could save nearly 2,000 yuan every year by prescribing medication, which made her happy. In fact, the content of chronic disease management is still expanding, and the core is centered around "allowing patients with chronic diseases to have fewer illnesses, less hospitalizations, and less money." After all, chronic diseases are a long-term matter, and they cannot be managed just by doctors looking at them in the clinic for ten minutes.