Exploring the Empowerment of Chronic Disease Management under the Multi-Party Linkage Mode
Zhang Mengjiao
Qian Ning
Cheng Ting
Abstract：China is the country with the largest number of diabetes patients in the world at present,but the overall control rate of patients'blood sugar is poor.As one of the important contents of family doctor's contracted services,chronic disease manage-ment should carry out targeted health education,strengthen the integration of sports and medicine,improve health literacy,and guide residents to practice the concept of"health first responsible person".Due to the influence of age and educational level,community patients cannot achieve the goal of forming a healthy concept for short-term outpatient and quarterly follow-up.Through the estab-lishment of a diabetes specialist team,which is composed of three-level hospital experts,general practitioners with specialized abili-ties,specialized nurses,and pharmacists,through the empowerment management under the linkage mode of full specialist outpatient services,regional medical federations,offline lectures,online science popularization,chronic disease group activities,chronic disease file data analysis,the awareness rate,blood glucose control rate,and standardized management rate of patients with diabetes can be improved.
Keywords：full professional integrationchronic disease managementmedical consortiumfamily doctor signing services
Publication Date：2023-12-10
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：3( 65-67 )