摘要
本文探索慢性病管理的有效路径。通过成立专门慢性病管理团队,借鉴慢性病管理模式,制定科学的慢病评估体系,开展远程健康管理,加强教育、宣传、监督力度,提高慢性病患者自我管理能力。通过一段时间慢性病管理,调查问卷反馈满意度明显提高,慢性病管理路径有效。因此,监测-评价-干预-再监测-再评价-再干预是慢性病管理路径的有效方法。
In this paper,the effective path of chronic disease management was explored.We set up a professional chronic disease management team,drew lessons from chronic disease management model,formulated scientific chronic disease assessment system, carried out remote health management,strengthened the education,publicity,supervision,and improved the self management ability of patients with chronic disease.Through a period of chronic disease management,the questionnaire showed that satisfaction was significantly improved,and the chronic disease management path was effective.In a word,monitor-evaluate-intervene-re monitor-reevaluate-re intervene was effective method for chronic disease management.
出处
《中国社区医师》
2016年第27期175-175,177,共2页
Chinese Community Doctors
关键词
慢性病
管理
临床路径
Chronic disease
Management
Clinical pathway
