Introduction to the Chronic Disease Management Department

The core of our Chronic Disease Management Department is to provide full-cycle disease management, complication prevention and quality-of-life maintenance services to patients with chronic diseases such as hypertension, type 2 diabetes, COPD, chronic kidney disease, and stroke sequelae that last for more than three months and require long-term intervention. To put it bluntly, we help you "manage" chronic diseases, avoid complications, and avoid emergency visits and hospitalizations.

Last week, an old patient came back for follow-up consultation. Aunt Li, 73, has been suffering from high blood pressure for 21 years. Before, she always felt that “if she’s not dizzy, she doesn’t need to take medicine.” She had a cerebral hemorrhage the year before last and half of her body was paralyzed. After she was discharged, she came to our department and we adjusted her plan of long-acting antihypertensive drugs. , came to check her blood pressure twice a week, and taught her husband to help with physical rehabilitation training. Now she can walk around the community on her own with a cane. Last week, she specially brought us her own pickled candied garlic. Of course, we didn't ask for it as per the regulations, but we felt very warm.

Speaking of which, there are actually two different intervention ideas in the chronic disease management circle. One is purely evidence-based Western medicine, which fully complies with domestic and foreign guidelines to adjust medicines and card indicators. Patients are required to strictly follow doctor's instructions and basically do not use non-drug intervention methods.； The other school prefers integrative medicine, which will incorporate traditional Chinese medicine physical therapy, diet and nutrition, sports rehabilitation and even psychological counseling. Indicators are not the only criterion. Our department is currently following both paths, and we will not impose a regimen on patients. For example, if you believe in Western medicine and find moxibustion and Baduanjin troublesome, we will adjust the most suitable medication regimen for you and follow up regularly to keep an eye on the indicators. ； If you are willing to try non-drug methods, we also have specialized Chinese medicine practitioners and nutritionists who will consult you and provide you with a suitable conditioning plan to make you feel comfortable. It is a good plan to control the disease.

People often ask, isn’t it okay to test indicators and take medicine at home for chronic diseases? Do I have to come to your department and spend the money? To be honest, not everyone needs to come to our department. If you have strong enough self-discipline, a clear understanding of your condition, your blood pressure and blood sugar are stable in the normal range all year round, and you don’t feel uncomfortable, you will have no problem taking care of yourself at home. We hope that the more patients like this the better. But most people really can't do it. For example, a 40-year-old programmer who was treated last month has had high blood pressure for three years. He often stays up late to catch up on projects. He takes medicine when he remembers it and doesn't take it when he forgets. When he came in, his blood pressure was 180 and he didn't feel anything. We gave him a blood pressure monitor with a reminder function and a mobile phone. It is bound to our follow-up system. If he forgets to take medicine, the system will send a text message to remind him. If the blood pressure test is abnormal, our nurse will call him as soon as possible to ask about the situation. Now it is almost 3 months, and the blood pressure is basically stable at 130/80. He himself said that he used to trade his life for money, but now he feels more relieved with us watching.

If it’s your first time to come to our department, don’t be nervous. We won’t give you a bunch of tests right away. When you enter, you first go to the nurse's desk to fill out a basic information form. We will ask you in detail whether you smoke, how many drinks you drink in a meal, whether you are a heavy drinker, and whether any relatives in your family have suffered from myocardial infarction or stroke. We will then create an exclusive health file for you. Now our system is connected with the community health service center in the jurisdiction. We can see your blood pressure, blood sugar, and physical examinations you usually do in the community in the backend, so you don't have to repeat the examination every time you come. Oh, yes, there is a free basket next to the nurse's desk, which contains sugar-free soda crackers, cherry tomatoes, and mineral water. Sometimes diabetic patients come for blood draws on an empty stomach, and after the draw they are hungry or have low blood sugar, so they can just take them and eat them. People in our department pool their own money to buy them, and they are not included in the charges.

I have been engaged in chronic disease management for almost 10 years. My biggest feeling is that chronic diseases are really not "incurable diseases". What I fear most are two extremes: one is not paying attention at all, thinking that there are no symptoms and not caring about them, and only regretting it when complications arise.； The other type is too anxious, buying health products randomly after listening to the useful ones on the Internet, and eating and taking supplements indiscriminately will damage the body. The meaning of our department’s existence is actually to serve as a “reliable health partner” for all patients with chronic diseases. You don’t have to look up information and figure it out on your own, and you don’t have to be afraid of being cheated. If you have any problems, come to us at any time. Let’s control the disease together and live a good life.