Chronic Disease Management Support Center

The core value of the Chronic Disease Management Support Center has never been the stereotype of "a convenient point for prescribing chronic disease drugs to the elderly", but a full-chain service carrier that fills the gap from hospital diagnosis and treatment to home self-management. Public data from the points currently implemented in China show that it can increase the control rate of patients with common chronic diseases such as hypertension and diabetes by about 37%, and at the same time reduce patients' annual medical expenses by nearly 20%.

Not long ago, I stayed at a chronic disease management support center in Gongshu District, Hangzhou for two weeks, and happened to meet Aunt Chen, who had suffered from hypertension for 11 years, for a monthly follow-up visit. In the past, she had to spend one afternoon every month to go to a tertiary hospital to register for a specialist. She would queue for two hours for a three-minute consultation. The doctor would leave after prescribing the medicine, without even bothering to ask her whether she had secretly eaten pickles recently or whether she was sleeping well. After this center opened downstairs last year, she didn't even have to pay for registration. A health manager asked her about her blood pressure via WeChat every week. Last month, she felt dizzy, so she got an arteriosclerosis screening within 10 minutes of arriving at the center. If there were any abnormalities, she was directly connected to the specialist she often saw before, saving her a lot of trouble of running to the hospital.

However, when it comes to the operational direction of chronic disease management support centers, there are still two completely different ideas in the industry. No one is right or wrong, but the people they are suitable for are different. One group is a down-to-earth clinical group, which believes that the essence of chronic diseases is still disease, and core services must be provided around medical resources. The center must be fixedly equipped with endocrinology and cardiovascular specialists, and all intervention plans must be supported by clinical guidelines. They cannot just make gimmicks of dietary therapy and exercise guidance. The pilots of this group are mainly in the old urban areas of first-tier cities, where there are many elderly patients with chronic diseases and high risks of complications, and they need to be able to connect with medical resources at any time. The other group is public health practitioners. They have looked at the data and found that 80% of chronic disease control problems are caused by living habits. Compared with seeing a doctor once a month, it is much more useful to have someone remind you to eat less salt, drink less milk tea, and take medicine on time. After all, many patients cannot control their indicators. To put it bluntly, they have poor compliance. They cannot control their mouths and cannot move their legs. Therefore, the core position of the center is It should be a health manager, sports rehabilitation specialist, or even a psychological counselor who can conduct daily follow-up thoroughly and raise the patient's awareness, so that they can naturally control the indicators. There are many pilots of this school in new urban areas where there are many young white-collar workers. Many young people in their twenties and thirties with high uric acid and high blood fat are unwilling to go to the hospital for medical treatment. Instead, they are willing to come to the center to find a nutritionist to ask how to eat takeaway without raising uric acid.

I have encountered a lot of people complaining before, saying that some centers are doing smart bracelet monitoring and it is too troublesome to upload data every day, and some people are worried about privacy leaks.； Some patients who live in the outer suburbs said that this thing is so convenient. If they forget to measure their blood pressure when they are busy, the bracelet will remind them and the data will be directly transmitted to the center. An abnormality manager will call them directly, saving them an hour of bus ride to the center. Another very real problem is that centers in many places are now understaffed. The busiest manager I have ever seen has nearly 2,000 registered patients in charge. Even if he does not take a break every day, it is impossible to follow up one by one. Therefore, many centers are now developing a "patient-to-patient mutual assistance" model. , looking for old patients who are well under control to serve as volunteers to help remind patients in the same community. Last time I met an uncle who had suffered from diabetes for 15 years. He controlled his sugar very well. He shared sugar-free recipes in the center's diabetes patient group every day, and the effect was much better than relying solely on staff to push notifications.

In fact, you don’t need to think about this center to be complicated. If there is one near your home, you can stop by and have a look around. You can get your blood sugar and blood pressure measured for free, and ask if staying up late recently will affect uric acid. No one will stop you. Don't think this is just for the elderly. There are really many people born in the 90s who suffer from high blood pressure and high uric acid. It is better to set up a file in advance to take care of it than to run to the hospital when complications arise, right?