Disease management should move forward systematically

Disease management should move forward systematically
Disease management should move forward systematically
Fit the loyal hospital high teacher Hua profile Yao high North China Beijing Yao and fit loyal hospital Beijing cardiovascularly and prevent and cure tutors of director, researcher, doctoral candidate in Beijing, prevent and cure association's Deputy Chairman, the cardiovascular members of expert panel of centre of prevention and cure of Ministry of Public Health in hypertension in Beijing. Mainly engaged in cardiovascular epidemiology research, diagnosis of the hypertension, treat, train and manage guidance with the slow disease of community with preventing, community's complete doctor. Have born the country " The Seventh Five-Year Plan Period " , " the Eighth Five-Year Plan Period " Brainstorm subject, the cooperation subject of World Health Organization, the project of health promotion of World Bank of Ministry of Public Health - Beijing,etc.. Has obtained four progress prizes in science and technology of Beijing, eight items of progress prize in science and technology of health bureau, two items of progress prize in science and technology of Ministry of Public Health. The traditional health care is the seperated health care: Prevent and treat and disconnect, the medical department separates with the medical insurance department, the means of payment of the medical insurance can't encourage the medical worker to launch preventing and health education. At present, are based on system and could guarantee to succeed in carrying on the idea of disease management, need people to clearly realize. It means many departments cooperate to manage disease based on system. Especially pay the system and combine together with the hospitalization cost, launch prevention of disease, diagnose, treat, strengthen the intersection of compliance and and manage, recover, the intersection of health education and integrated health care of continuation oneself of patient in early days. And it is transition which needs time and idea to set up one to the health care system that is combined, need the gradual changes of experience and organization. Disease will finish disease and manage the purpose including two to click through the group while managing: First, improve the patient's health level; Second, reduce the hospitalization cost. It is the best tactics to be with low costs, effectual while launching the disease management, its work just has sustainability. It is not merely a thing of the hygiene service organization of the community that disease is managed, tertiary hospital, disease controlling organization, recovery centre, pharmaceuticals,etc. should all cooperate closely, play a their own role. The patient, and is responsible for the training of the doctor at the basic level as the tertiary hospital should admit and change the place of examination; The controlling organization of disease should be responsible for health promotion and health education of the community,etc.. The most important thing is in the management system of disease the medical insurance department, because the means of payment of the medical treatment and health care is the key to it is determined what level and stage disease is managed and ating. The information system is that the platform will make the health care plan to each patient's situation if the platform launches chronic disease management, carry on reviewing and comprehensive analysis to the patient's clinical materials, inspection result, appraise the patient's administrative situation at any time, is adjusting our health care plan constantly. The administrative service division wants the crowd of control over whole to appraise. It is very difficult to accomplish that all these have no platform of information system. Hygiene health service and work of disease management of construction community of the group should be finished by group, the members in the group should have division of labour and cooperate. The groundwork of the complete doctor is to make a diagnosis, need to accept various continuing education and train constantly, know newest following the medical progress of the card in order to apply to complete medical treatment. Slow disease management needs full-time disease administrative staff holding a part-time job, accept that carries on the work after training, its main duty is to make the patient's health care plan, offer latest following the medical information of the card, provide for patient and family and intervene, guide and comment on clinically, do communication and work of changing the place of examination if necessary of other personnel in the team well and keep healthy. The conditional community should also be furnished with nutritionist, recovering in the division, druggist,etc.. The traditional group concept is that a patient comes to the clinic doctor, dispensary personnel, course such as personnel of collecting money, the members of the group are in the face of the same patient, but never exchange each other. The new group concept is that every medical worker should know goal and task of disease management, understand health care plan and how about raise the quality, share responsibility, mutual trust. Each member should understand one's own role, responsibility and work while keeping in touch with the patient. Launch the first step of tactics course of disease management: Sift and look into the patient, must consider the questions of manpower, material resources to sift the method to check to register while going on. Can usually use the following methods: Can register and verify from the patient finding out management taken in the health file that has already been set up, preferably connect the health file with information system of making a diagnosis conventionally of the community, launch the health service of the continuation; Find to the regular physical examination the patient who belongs to the range of management registers etc.; The ones that go to a doctor to the regular clinic, patient who belongs to the range of management register etc.; The sieve of other routes checks, for instance epidemic disease is investigated. Second step: Prepare community patient of management, go on, it divides layers into to be numerous the patient, should be with particular emphasis at the time of management, main energy wants the crowd who put to the high, self- health care of dangerous degree with bad consciousness to have. The laminal purpose should confirm the intensity of the way and intervention of the frequency, intervention that different patients of layer follow up a case by regular visits to. Generally divide 3- 5 layers. Take hypertension as examples, can divide layer like this: It is gt of blood pressure on the third floor; 140/90mmHg, and there are the hypertension patients of complication and relevant clinical situation; Ones that have no complication and relevant clinical situation on the second floor, gt of blood pressure; Hypertension patient of 140/90mmHg, has not monitored blood pressure regularly; It is all other hypertension patients on the first floor. Third step: Make the actual conditions that health care plans to be directed against each patient to the patient's individual situation, set up small concrete goal under the patient's common participation step by step, reach the final goal progressively. Such as instructing the patient how to reduce and weigh, the first step can be determined as changing the deep-fried twisted dough sticks of breakfast into a steamed bun or bread. Some communities regard it as the main content of management to measure blood pressure for the patient every month, the content that in fact examines blood pressure or measures the fat of blood etc. and just monitors regularly, it is not a main content of management. It is not merely science, or the combination of science and art to manage a patient well. Each resident's question is different, some people forget to take medicine, some people are afraid there is side effect and refuse to obey medicines in medicines. The skill that the medical worker should learn to communicate with the patient, establish the good relationship between doctors and patients, in this way the patient's compliance will be strengthened. Fourth step: Follow up a case by regular visits to the content of following up a case by regular visits to to the patient of management regularly and not merely include the clinical index, also include the situation that the behavior changes, such as the patient has reduced the absorption of the salt, given up smoking etc.. Manage and intervene the way to have guidance of telephone consultation, post the health education material or surf the Net to read and visit the parents to the doorstep in disease with common method. Intervention way in which the low patient of dangerous degree can adopt the characters material which posts the health education or surf the Net and read. Cost of this way is the lowest, but it is relatively bad to intervene the result. Most patients' management adopts the way of intervening in telephone, it is medium-sized to intervene the cost the telephone, high in efficiency, It is medium-sized to high to intervene the result. Adopt the telephone to interfere everybody from probably accounting for the left for 20 minutes? Hu Γ The short wooden stake gruel unloads  and trains in peaceful summer carefully Die is forgiven Bits Qi of cheek furan punishment faint Yu  train and raise Yi ァ? Manage disease and manage the improvement that the key to success is the patient's self- managerial ability. What respects does the patient's self- managerial ability include? Take hypertension as examples, the patient's self- managerial ability mainly includes: To the ability that one's own blood pressure monitors, the ability which the patient assesses to one's own blood pressure, the patient is applied to the medicine and the simple understanding of the side effect, the patient strengthens the complying with ability of medicine, the patient knows the basic skill that the behavior corrects, choose the food, ability to carry on physical training, give up smoking, stop drinking, reduce the heavy, pressure management skill, seek the ability of health knowledge and ability to seek medical advice. Understand and carry out relevant technological guides and norms that the medical association, community hygiene association make in training, it is the main content that the doctor trains. The information that the technological guide offers is authoritative, are proved the suggestion of reaching an agreement collectively by experts according to following results of medical research of the card in a large amount. So doctors should know the spirit of the technological guide and apply to the medical practice, could provide the best medical treatment and health care for patient in this way. Coordinate the important content that the health service of the hygiene is disease management, will set up changing the place of examination and emergency call passway for the patient. When needing changing the place of examination in condition, doctors at the basic level should know the standard of changing the place of examination. Should set up the passway that changed the place of examination bidirectionally for the patient while managing a responsibility teacher, further go to the hospital of higher level to go to a doctor to provide convenience for the patient in disease, the unnecessary checking repeatedly of reduction, save hygiene funds. It is very important too for disease management to succeed or not to appraise and measure the result. These results feedbacked are for finding out the deficiency of management, it is very helpful to improve disease and manage quality. Should measure the following aspects to intervene the result to appraise: The clinical result measures clinical index, complication, having illness coming on and the situation dies,etc.. It last hospitalization cost funds result, in hospital, emergency call and clinic number of times, lasting daying, life quality. The behavioral result measures compliance, the patient's self- managerial ability of patient and doctor. The service quality result measures the patient's satisfaction, the doctor's satisfaction and the administrator's satisfaction. Disease management was developed until today, method and tactics have been already standardization, but the technology of management is still developing constantly. Whom the target crowd of disease management is directed primarily to is an ill crowd, so proceed from health goal of the whole crowd of the community, disease will be turned from the individual to the health control based on crowd when being managed. Relevant materials: Disease management originated from the end of 1990s, is being paid attention to in recent years. It usually chooses diseases such as hypertension, diabetes, asthma, depression,etc.. Often hospitalization cost relatively high disease these, through carry on health education and training of doctor to patient, will improve the therapeutic effect greatly, improve the compliance of patient's treatment, reduce complication and death.


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