National Health Commission： Four measures to promote chronic disease management

　　Cctv newsOn December 5, the National Health and Wellness Commission held a press conference to introduce the measures to deepen the implementation of grassroots health care and convenience services. Zhu Hongming, deputy director of the Grassroots Department of the National Health and Wellness Commission and a first-class inspector, said at the meeting that since the deepening of medical reform in 2009, National Health Commission has continuously promoted the equalization of basic public health services, and grassroots medical and health institutions have undertaken a large number of basic public health services, especially the health management of patients with chronic diseases, and have established relatively stable contacts with urban and rural residents. Many urban and rural residents have already felt this service. In promoting the management of chronic diseases, there are mainly the following measures:

　　First, in the grassroots convenience measures, we will promote the full implementation of long-term prescription services for chronic diseases such as hypertension and diabetes in community health service centers and township hospitals, and gradually expand the coverage of chronic diseases; Provide exercise and diet prescriptions or suggestions for patients with chronic diseases such as diabetes, hyperlipidemia and hypertension.

　　The second is to organize the compilation of the National Guidelines for the Prevention and Control of Hypertension and the National Guidelines for the Prevention and Control of Diabetes, so as to guide local primary medical and health institutions to provide health management services for patients with chronic diseases.

　　The third is to actively promote the training of "medical prevention and management" integrated talents and establish a medical prevention and control integration mechanism. Relying on the contract service of family doctors, we will promote the combination of prevention and medical care, do a good job in health follow-up of key populations, and carry out multi-disease co-management services for patients with chronic diseases such as hypertension and type 2 diabetes, mainly through the integration of medical care and prevention.

　　Fourth, relying on the construction of county medical community, promote the establishment of division of labor and cooperation and two-way referral mechanism between primary medical and health institutions and superior medical institutions, and extend the services of superior hospitals to the grassroots. For patients with chronic diseases with stable conditions, health management services are provided by grass-roots institutions in accordance with norms and guidelines. There are some good explorations and practices in this regard in various places, for example, Tianjin promotes the construction of grass-roots chronic disease management centers, and provides residents with online and offline integrated all-round and full-cycle health services through intelligent auxiliary diagnosis, convenient chronic disease assessment, customized treatment programs and personalized health management. Relying on the construction of county medical associations and urban medical associations, Zhejiang Province has realized that the general diagnosis, treatment and daily management of "two chronic diseases" are mainly based on grass-roots medical and health institutions, realizing linkage from top to bottom and smoothing referral channels.