Chronic disease management center construction standards

The "Chronic Disease Management Center Construction Standard" currently does not have nationally unified mandatory implementation details. The mainstream consensus in domestic implementation is to build it around the three core dimensions of "hardware adaptation, service standards, and operational sustainability." At the same time, the weight is adjusted according to the level of the construction entity (community health service center/secondary hospital/tertiary hospital). There is no absolutely universal template.

It's interesting to say that last year, I followed the chronic disease teacher of a certain district's disease control department to inspect three community health service centers, and happened to encounter a counterexample: In order to be evaluated as a provincial demonstration, a community copied the construction plan of a chronic disease center of a tertiary hospital, and spent hundreds of thousands to install 200 The flat independent ward is equipped with a full set of electrocardiogram monitoring equipment, but half of the area was empty during the acceptance check. Most of the chronically ill people from the community are prescribed antihypertensive drugs and fasting blood sugar tests. There is no need for observation at all. The monitors installed at a high price are only used twice a week. In the end, half of the ward was demolished and converted into a health education classroom. Several long tables were set up. Every Wednesday afternoon, I taught the uncles and aunts how to prepare a low-salt diet. On the contrary, the monthly follow-up rate for two diseases (hypertension and diabetes) increased by 30%.

Regarding the priority of construction standards, the industry has been arguing for almost five years without reaching a unified conclusion. One group is a proponent of “prioritizing medical attributes”. Most of them are chronic disease doctors from second-level hospitals and above. They believe that the chronic disease center must first have clinical processing capabilities and at least two chronic disease specialists with associate senior professional titles. It must have fast access to the laboratory department and imaging department and be able to identify the risk of complications at the first time. Otherwise, it will be no different from a community health education point. The chronic disease center of a tertiary hospital in Sichuan is following this route. It has opened special disease management posts for people at high risk of diabetes, kidney disease and stroke. Last year, it screened more than 2,000 patients with early complications. After timely referral, the average annual hospitalization expenses of the patients dropped by nearly 40%. The results are indeed impressive.

Supporters of the other group of "service attributes first" are basically grassroots public health practitioners. They feel that for community-level chronic disease centers, access capabilities are much more important than diagnosis and treatment capabilities. They do not need to be equipped with high-end medical equipment. As long as follow-up is in place and patients are given clear guidance on medication and lifestyle, that is enough. Chronic disease centers in many communities in Shenzhen do this. They link chronic disease follow-up with family doctors and community grid staff. The elderly do not need to go to the hospital. The grid staff will check their blood pressure when they come to take nucleic acid tests. If the blood pressure is high for two consecutive weeks, they will directly help make an appointment with a higher-level hospital. The current high blood pressure control rate in local communities is 12 percentage points higher than the national average, and the data is also very beautiful.

Many people think that hardware is enough, but in fact the easiest thing to get into trouble is the service details. I have seen many chronic disease centers develop a bunch of standardized follow-up questionnaires, asking the elderly to fill them out for 20 minutes each time they come. The words are small and the questions are obscure. After two visits, the elderly find it troublesome and are unwilling to come. Instead, a community nurse broke down the scale into common questions. When entering the door, she first asked, "Have you been dizzy recently?" How many times do you get up at night? I told you last time to use less soy sauce. Have you paid attention to it when cooking recently? ”The required data was collected in three or two minutes, and the old man was not stressed. There is also the hotly debated question "Should I use the AI ​​follow-up system?" Some places think that automatically calling and sending WeChat reminders can save manpower. Some places think that the machine is too rigid and the elderly will not answer it at all. In fact, there is no standard answer? For young patients under 70 years old, it is very convenient for AI to send a WeChat reminder to prescribe medicine. For elderly people over 80 years old who live alone, asking a nurse to knock on the door once a week is more effective than making 10 phone calls.

Whether the operation can be managed is the core reason why many chronic disease centers fail after they are built. The two current mainstream models are also controversial: one is based on capitation payment by medical insurance, which gives the chronic disease center an annual management fee of 100-200 yuan per person. As long as the patient's control reaches the standard and is not hospitalized due to complications, the full amount of the money will be allocated. Many people complain that this model is easy to fake, and you can deceive the medical insurance by filling in a few normal blood pressure data. ； The other is low-cost paid services, such as a membership fee of 99 yuan a year, which includes monthly blood sugar testing, door-to-door dressing changes, and priority appointments. Some people think this is to make money from the elderly and increase prices in disguise. But it has to be said that both models have partly worked together. Pure public welfare chronic disease centers that rely entirely on financial allocations have ended up being empty shelves due to insufficient funds and manpower.

After visiting 20 or 30 chronic disease centers at different levels across the country, my own feeling is that all the standards written on paper are dead. The only hard indicator is actually "whether the chronic disease people near your home are willing to come." Some centers are decorated like high-end medical examination institutions. As soon as the elderly enter the door and look at the shiny marble floor, they feel intimidated. They think it will cost a lot of money and dare not enter. ； On the contrary, there are free weight scales and blood pressure monitors at the door, and the nurse will take the initiative to say hello and hand over a cup of hot water when seeing the elderly passing by with vegetables. The management effect will not be bad if it is overcrowded every day.

Recently I heard that the national chronic disease management center guidance standards are already soliciting opinions and may be released next year. However, no matter how the provisions are changed, the core standards that can reduce the incidence of complications and make people feel that they are really useful are the core standards that will never change.