Chronic Disease Management Center

The core value of the Chronic Disease Management Center is to help patients with chronic diseases break out of the vicious cycle of "going to the hospital only when they are sick, relying on hard work, and relying on memory when taking medicine." It shifts the focus of disease intervention from the treatment side to the prevention side, and ultimately helps patients stay in the hospital less, suffer less, and spend less money.

When I did some research at the Xicheng Community Chronic Disease Center, I met 62-year-old Uncle Zhang, who has been suffering from high blood pressure for 12 years. He always believed that "medicine is 30% poisonous" and would never take medicine unless he was dizzy. The winter before last year, he had a sudden cerebral hemorrhage and was hospitalized in the ICU for 7 days, which cost him nearly 80,000 yuan. Half of his body was numb for half a year before he recovered. Later, he was transferred by the community to a chronic disease center for file management. Now his blood pressure has been stable for 18 months. The dizziness and migraines he often suffered before have rarely come to his door. Even the annual expenses of his medical insurance account have been reduced by half compared with before.

Don’t think that this thing is a “panacea.” The industry has been arguing for almost five or six years about how the chronic disease management center should be run. Both schools of thought have their own merits.

One group is the "medical core group", which believes that the essence of chronic disease management is medical behavior, and the specialized resources of tertiary A hospitals must be pooled for patients to buy into it. I have seen a center in Chaoyang before. The deputy director of the cardiology department of An Zhen is invited to sit in for consultation every Wednesday. In the first month of the clinic, the patients with appointments were queued from the registration office to the entrance of the alley. Grandpa and aunt would rather take a half-hour bus ride to see a specialist for medication. But only three months later, the follow-up consultation rate has dropped by 40% - it is too difficult to get a specialist's number, and you have to wait for two hours every time you come. Most patients just get regular antihypertensive medicines. This trip is not as convenient as having their blood pressure measured at the pharmacy at their doorstep and prescribing some medicine at will.

The other group is the "service core group", which believes that 90% of patients with chronic diseases do not need experts at all on a daily basis. What they lack is someone to keep an eye on them: someone reminds them if they forget to take medicine, someone complains if they can't control their mouths, and someone intervenes in advance if the indicators are floating. There is a street center in Shanghai that does this. A small group is formed for each registered diabetic patient. Three health managers take turns to monitor the system. They remind people to test their blood sugar and check their diet every day. Every week, a nutritionist adjusts the diet based on blood sugar conditions. When it was first implemented, patient satisfaction was particularly high. But then something went wrong: There was a 70-year-old man whose blood sugar suddenly spiked to 21mmol/L. The health manager in the group did not have the right to prescribe medicine and did not dare to dispense medicine casually. The man went to the emergency room of a tertiary hospital and it took him a long time to stabilize. Then he left the group and said, "This place is not useful at this critical moment."

In the past two years, many centers have also been trying to find the middle way. I went to a street center in Xiacheng District, Hangzhou last month for research. The "1+1+N" model they have adopted is quite interesting: an endocrinology/cardiology expert from a tertiary A hospital serves as a consultant, and does not have to work every day, but opens online cases once a week. seminars to deal with difficult cases; a resident general practitioner is on duty and can handle daily medication, prescriptions, and preliminary diagnosis; the remaining N health managers, nutritionists, and exercise instructors are dedicated to follow-up daily follow-up, taking care of trivial matters such as medication reminders and diet and exercise guidance. Last year, among the 827 patients with hypertension and diabetes under their care, the blood pressure and blood glucose compliance rate increased from 42% to 78%, and the annual hospitalization rate dropped by 29%. These are all real data obtained by the medical insurance system.

To be honest, I also thought the chronic disease management center was a "showy" for the past two years. Until last year, I accompanied my mother to a center near my home to measure blood sugar. The nurse there actually remembered that the last time my mother came here, she said that her knees hurt and she didn't dare to walk much, especially Yiyi gave me a low-weight-bearing exercise guide specifically for diabetics. Even details such as not wearing hard-soled shoes when dancing square dance and not dancing for more than 40 minutes were marked in red. At that time, I felt that if this thing could be implemented, it would be better than anything else.

Of course, there are many problems now. The resources in different regions are very different. Some centers in remote areas and counties do not even have an instrument that can formally measure glycated hemoglobin. There are also commercial centers that charge excessive fees. It costs thousands to apply for an annual card. They just sell health care products to you every day. This has ensnared many elderly people and has never stopped controversies. But there are more than 300 million patients with chronic diseases in our country. We can’t rush to tertiary hospitals every time there is a slight fluctuation in indicators. Having a place like this can help us keep an eye on our daily status and block major illnesses into minor ones. It is worth pursuing anyway.