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The full name of chronic non communicable diseases is chronic non communicable diseases. Chronic non communicable diseases consist of a series of chronic diseases, including cardiovascular diseases, diabetes, chronic respiratory diseases and mental diseases, which are characterized by a long incubation period and a long course of disease, leading to patients' weakness or loss of function.
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Chronic management is a systematic project that cannot be narrowly understood as the management of chronic diseases. It should also utilize its various elements (human, financial, material, information, and time and space) and utilize management methods to maximize the social utility of chronic disease management.
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Chronic disease management is more about changing a person's cognition and then changing their behavior, allowing them to achieve lifestyle changes. This requires us to have a long-term, sustained, and profound impact on the cognitive level of patients through a means.
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The system has the ability to manage patients in 220 special diseases, including epilepsy, asthma, diabetes, hepatitis B, and enteral nutrition, and has achieved preliminary and effective medical results. In the digital patient management model, patients' initiative in self-managing diseases is more easily stimulated, and medication compliance and quality of life are significantly improved.
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Taking the enteral nutrition rehabilitation center as an example, after 95 days of participation in management, the average number of medication days per patient increased by 70%. Through continuous tracking, it was found that among patients participating in enteral nutrition programs, more than 83% of patients who lost weight (BMI value less than 18.5) at the time of initial filing improved their weight.
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How about effectiveness management and is patient management truly effective?
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Medical institutions can adopt a professional chronic disease specialist follow-up+AI artificial intelligence follow-up system, which interfaces with the HIS system to perform graded follow-up management on outpatient and discharged patients, achieving precise follow-up. Each role in the community can accurately intervene and assist patients with poor disease control based on their condition. The worse the patient's disease management, the stronger the intervention methods and frequency. At the same time, long-term tracking of patients' behavior after receiving intervention is carried out 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 enable patients to have the ability to self-manage in a short period of time, which can accompany them for a lifetime; The second is to accompany patients throughout the long course of their illness, to have their questions answered and to have companions during their interactions with the disease. In response to this, the community based on Enterprise WeChat will periodically invite rehabilitation patients among patients to share their experiences, and use the power of role models to help patients build confidence.
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The major advantage of basic medical participation in chronic disease management is that it can be more closely integrated with the entire treatment process. The advantage of offline coaches is that they can provide more detailed guidance on exercise, diet, and lifestyle to change users' living conditions and promote the treatment of chronic diseases. Adopting a new service model of "basic healthcare+offline coaches+community sharing", making medical services more warm and providing patients with a sense of gain.
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This article is dedicated by the Chronic Disease Follow up Management System. For more information, please click on: Sincere attitude. We will provide you with comprehensive services. We will gradually contribute more relevant knowledge to everyone. Stay tuned
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