What are chronic disease management

From the perspective of front-line chronic disease management practitioners, the core of chronic disease management services currently implemented in China is full-cycle care for long-lasting chronic diseases such as hypertension, diabetes, and chronic obstructive pulmonary disease that cannot be completely cured. The core modules include daily indicator monitoring, standardized medication management, personalized lifestyle intervention, early screening for complications, and psychological and social support. It is far from as simple as "regularly measuring blood pressure and blood sugar" as everyone thinks.

I have been doing chronic disease management in a community health service center for almost seven years. Among the thousands of patients I have come into contact with, many of them had a biased understanding of this matter at the beginning. The one who impressed me the most was Aunt Wang in the district last year. She had been suffering from diabetes for 12 years. She used to take anti-diabetic drugs blindly, and only took them when she remembered. Her blood sugar fluctuated and she was hospitalized for ketoacidosis. After she was discharged, she helped us with chronic disease management. We first created an exclusive health file for her and sorted out her previous hospitalization records and medication history. We first corrected her previous bad habit of cutting down on medication and buying health-care hypoglycemic products indiscriminately. We adjusted the medication plan based on her liver and kidney function, and also set up a medication reminder for her. A small sticker is posted on the refrigerator. She usually comes to the community to test her fasting blood sugar twice a week. We have also equipped her with a home blood glucose meter. The values can be posted to our chronic disease management group at any time. If there is any abnormality, I will call to ask about the situation as soon as possible. If it is continuously high, I will contact the family doctor to adjust the plan.

Aunt Wang usually likes to cook white porridge and eat candied fruits. We specially brought her daughter to give her dietary guidance, taught her how to convert the glycemic index of food, and found home-cooked recipes suitable for diabetics. She was also asked to dance in the community's chronic disease exercise classes every Wednesday. Gradually, she lost 6 pounds and her blood sugar stabilized a lot. Every six months, we remind her to undergo fundus, kidney function, and foot nerve screenings because we are afraid that she will develop complications such as diabetic foot and retinopathy over time. Early detection and early intervention can save a lot of trouble and save a lot of treatment costs. In the past, Aunt Wang always felt that she was a burden on the family because of her unstable blood sugar. We also contacted the mental health doctor in the district to give her two psychological counseling sessions. Now she has become a promoter of our chronic disease management group and often shares her sugar control experience with new diabetics who join the group.

Now there are different voices in the industry on the implementation form of chronic disease management. Some organizations are mainly promoting intelligent equipment, equipping patients with smart bracelets and connected blood glucose meters, and real-time data is sent back to the background for automatic warning. Many of our frontline practitioners believe that this kind of digital tool can only be used as an auxiliary. After all, many elderly people do not know how to use smart devices, and chronic disease management often has to take into account the emotional value. Sometimes a few homely words during home visits are much more effective than cold warning text messages. To put it bluntly, chronic disease management is like assigning a long-term "health partner" to patients with chronic diseases. They do not wait for you to get sick before going to the hospital for emergency treatment, but help you eliminate various small hidden dangers that may aggravate the condition. The ultimate goal is to allow patients to be hospitalized less, suffer less, and improve their quality of life.