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- 2023-03-22
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- 130
Medical institutions can adopt a set of professional chronic disease specialist follow-up+Kangce AI artificial intelligence follow-up system. Through interfacing with the HIS system, they can conduct hierarchical follow-up management for archived outpatient and discharged patients, achieving accurate follow-up. Various roles in the community can accurately intervene and assist patients with poor disease control based on the patient's situation. The worse the patient's disease management, the stronger the intervention method and frequency. At the same time, long-term tracking of patients' behavior after receiving intervention is conducted through the system to ensure that cognitive education for patients can be translated into actual behavioral changes, and ultimately drive the disease to develop for the better.
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"Peer assistance" during the long rehabilitation process is also very important. In the new service model of digital patient management, there are actually two core competencies: one is to provide patients with the ability to manage themselves in a short period of time, which can accompany them for a lifetime; The second is to accompany patients during the long course of their illness, allowing them to have their questions answered, and to have companions during their interactions with the disease. In response, through the WeChat based community, rehabilitation patients among patients are invited to share their experiences from time to time, using the power of example to help patients build confidence.
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In order to prevent and treat chronic diseases, reduce the burden on residents, and improve life expectancy, the State Council has issued the "Medium and Long Term Plan for the Prevention and Treatment of Chronic Diseases (2017-2025)", which proposes to adhere to prevention first, strengthen the control of behavioral and environmental risk factors, strengthen early screening and detection of chronic diseases, and promote the transition from disease treatment to health management. The Plan aims to reduce the premature mortality rate of 30-70 year olds due to cardiovascular and cerebrovascular diseases, cancer, chronic respiratory diseases and diabetes by 10% and 20% respectively from 2015 by 2020 and 2025.
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The biggest advantage of basic medical care participating in chronic disease management is that it can be more closely integrated with the entire process of treatment. The advantage of offline coaches is that they can more carefully guide users through exercise, diet, and lifestyle to change their living conditions and promote the treatment of chronic diseases. The new service model of "basic medical care+offline coaches+community sharing" is adopted to make medical services more warm and provide patients with a sense of gain.