Chronic disease management in the community

1. Main categories of chronic diseases:

Hypertension, diabetes, tumors, cardiovascular and cerebrovascular diseases, COPD

Score: daily prevention, discovery methods, Follow-up management

2. Prevention and treatment of chronic diseases:

One liter: Improve residents' healthy lifestyle.

The second morning: early detection and early treatment.

Three reductions: reduce disease incidence, disability and death.

Example: type 2 diabetes

3. Service content:

(1) Screening

Type 2 diabetes discovered at work People at high risk of diabetes receive targeted health education, and it is recommended that they measure fasting blood sugar at least once a year and receive health guidance from medical staff.

(2) Follow-up evaluation

For patients diagnosed with type 2 diabetes, free fasting blood glucose testing is provided 4 times a year and at least 4 face-to-face follow-ups are conducted.

(1) Measure fasting blood sugar and blood pressure, and evaluate whether there is a critical situation, such as blood sugar ≥16.7mmol/L or blood sugar ≤3.9mmol/L; systolic blood pressure ≥180mmHg and/or diastolic blood pressure ≥110mmHg ; Changes in consciousness or behavior, rotten apple-like acetone smell in breath, palpitations, sweating, loss of appetite, nausea, vomiting, polydipsia, polyuria, abdominal pain, deep breathing, skin flushing; sustained tachycardia (heart rate) More than 100 times/minute); when the body temperature exceeds 39 degrees Celsius or there are other sudden abnormalities, such as a sudden drop in vision, higher than normal blood sugar during pregnancy and lactation, or any other dangerous situation, or there are other diseases that cannot be treated, Emergency referral is required after treatment. For emergency referrals, township health centers, village clinics, and community health service centers (stations) should proactively follow up on the referral status within 2 weeks.

(2) If urgent referral is not required, ask about the symptoms from the last follow-up to this follow-up.

(3) Measure body weight, calculate body mass index (BMI), and check dorsalis pedis artery pulse.

(4) Ask the patient about his disease status and lifestyle, including cardiovascular and cerebrovascular diseases, smoking, drinking, exercise, staple food intake, etc.

(5) Understand the patient’s medication status.

(3) Classified intervention

(1) Satisfied with blood sugar control (fasting blood sugar value <7.0mmol/L), no adverse drug reactions, no new complications or existing Patients whose complications do not worsen will be scheduled for the next follow-up visit.

(2) For patients who are dissatisfied with fasting blood sugar control (fasting blood sugar value ≥7.0mmol/L) or have adverse drug reactions for the first time, guidance will be given based on their medication compliance, and if necessary, the existing Drug dosage, replacement or addition of different types of hypoglycemic drugs, and follow-up within 2 weeks.

(3) For patients who have unsatisfactory fasting blood sugar control or difficult to control adverse drug reactions for two consecutive times, as well as new complications or aggravation of existing complications, it is recommended that they be transferred to a higher-level hospital. 2 Actively follow up on referral status during the week.

(4) Provide targeted health education to all patients, set lifestyle improvement goals with the patients and evaluate progress at the next follow-up visit. Tell the patient what abnormalities should be seen immediately.

(4) Physical examination

Patients diagnosed with type 2 diabetes should undergo a comprehensive physical examination once a year, and the physical examination can be combined with follow-up. The content includes routine physical examinations such as body temperature, pulse, respiration, blood pressure, height, weight, waist circumference, skin, superficial lymph nodes, heart, lungs, and abdomen, as well as rough measurement and judgment of oral cavity, vision, hearing, and motor functions. For specific content, please refer to the health examination form of the "Health File Management Service Standards for Urban and Rural Residents".

Service requirements

(1) The health management of patients with type 2 diabetes is the responsibility of doctors and should be combined with outpatient services. For patients who fail to receive follow-up in accordance with health management requirements, the township Health centers, village clinics, and community health service centers (stations) should proactively contact patients to ensure continuity of management.

(2) Follow-up includes making appointments with patients to outpatient clinics, telephone follow-up and home visits.

(3) Township health centers, village clinics, and community health service centers (stations) should screen and detect type 2 diabetes patients through community health diagnosis and outpatient services in the region, and understand the status of residents in their jurisdictions The prevalence of type 2 diabetes.

(4) Give full play to the characteristics and role of traditional Chinese medicine in improving clinical symptoms, improving quality of life, and preventing and treating complications, and actively apply traditional Chinese medicine methods to provide health management services for diabetic patients.

(5) Strengthen publicity and inform service content so that more patients are willing to receive services.

(6) Record relevant information in the patient’s health file promptly after each service is provided.