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.

慢性管理是一項系統性工程，不能狹隘地將慢病管理理解成慢性病的管理，還應當利用其各個要素(人、財、物、信息和時空)，借助管理手段，使慢病管理的社會效用大化。

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.

慢病管理更多的是改變一個人的認知，進而去改變他的行為，讓他獲得生活方式上的改變。這就需要我們通過一種方式，能夠長期、持續、深度地去影響患者的認知層面。

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.

系統具備癲癇、哮喘、糖尿病、乙肝、腸內營養等在內的220個專病病種領域的患者管理能力，且取得了初步有效的醫學結果。在數字化患者管理模式下，患者自我管理疾病的主動性更容易激發，用藥依從度和生活質量明顯改善。

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.

以腸內營養康復中心為例，患者在參與管理后95天，人均用藥天數提升70%。通過持續跟蹤發現，參與腸內營養項目的患者中，初次建檔時身體消瘦（BMI值小于18.5）的患者中，超過83%體重得到改善。

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.

效果管理如何，患者管理是否真正有效？

How about effectiveness management and is patient management truly effective?

醫療機構可以采用一套專業的慢病專科隨訪+AI人工智能隨訪系統，通過和HIS系統進行對接，對建檔的門診、出院患者進行分級隨訪管理，實現精準隨訪。社群中的各個角色可以根據患者的情況精準干預和幫扶疾病控制不佳的患者，患者疾病管理情況越差，干預方法和頻次就越強。同時，通過系統對患者接受干預后的行為進行著長期追蹤，確保對患者的認知教育能夠轉化為實際的行為改變，并終帶動疾病向好發展。

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.

漫長康復過程中的“同伴互助”也非常重要。在數字化患者管理新服務模式中，實際有兩大核心能力：一是短時間內讓患者有自我管理的能力，這個能力可以伴隨終身；二是陪伴患者漫長的病程里，讓他們的問題有人解答，與疾病相處的過程中有同伴。針對此，通過基于企微微信的社群會不定期邀請患者中的康復患者分享經驗，用榜樣的力量幫助患者樹立信心。

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.

基礎醫療參與慢病管理的大優勢是可以與治療的整個流程結合得更為緊密。線下教練的優勢是可以更細致地通過運動、飲食、生活方式指導去改變用戶的生活狀態，促進慢病治療。采用“基礎醫療+線下教練+社群分享”的新服務模式，讓醫療服務更有溫度，讓患者更有獲得感。

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: http://www.cnjinxinmweb.cn Sincere attitude. We will provide you with comprehensive services. We will gradually contribute more relevant knowledge to everyone. Stay tuned