What are the contents of chronic disease management?

Chronic disease management includes early screening, chronic disease risk prediction, early warning and comprehensive intervention, comprehensive management of chronic patients and evaluation of chronic disease management effect.

Chronic disease management refers to the medical behavior and process of regular detection, continuous monitoring, evaluation and comprehensive intervention management of chronic non-communicable diseases and their risk factors.

The term health management appeared in China for about 10 years. With the emergence of health examination institutions, the concept of health management has gradually spread. However, the physical examination center only intercepted one or several links of the health management service system, and did not really realize the value of health management service. At present, many health service institutions (mainly community health service centers) in China have carried out health management services aimed at improving patients' quality of life and reducing medical expenses while treating diseases. ?

The object of chronic disease management is the phenomenon that the behavior and action of chronic disease management directly point to and want to change. In essence, the object of chronic disease management is an artificially defined scope, which indicates "what cares about you", so the demarcation of chronic disease management object not only leads the direction of chronic disease management, but also determines the success or failure of chronic disease management.

Judging from the current policy, the management object of chronic diseases is "chronic non-communicable diseases". According to the published Research Report on Chronic Disease Management Practice, the object of chronic disease management is not only chronic non-communicable diseases, but also the cognition, behavior and motivation of patients with chronic non-communicable diseases.