| BackgroundWith population aging, change of family structure, change of spectrum of disease and medical system reform, economic and effective community health service has become the trend of modern health services. With economy development and urbanization, hypertension, diabetes, hyperlipidemia has become one of the common diseases in community population, andshowed the tendency of more young age, diseases prevention and disease reducation has become a the main task among community health service.The national basic public health service regualation have caterized hypertension, diabetes, and stroke into the chronic disease management and management effectiveness is significant. Due to the number of patients with chronic disease and those not included in the range of chornic disease managementincreasing year by year, how to make use of existing national public health platform to cover the entire community residents with chronic disease, how to make full use of health resources, and how to improve the level of health among all the chorinc disease patients are the chanllenge for public community health service.PurposesBasied on the research of chornic diease health management, to explore the concept, method, theory basis of choronc disease health management, to combine the reaility of local community health center, to develop method of chroinc disease health management in community, and to put basis for future management.MethodsThe data came mainly from the health management promotion work in two community health centers, which included the compile of chornic disease health education matarial by literature review, full evualtion of the residents through face to face investigation, and second round asessment and health education needs through telephone calls. IBM SPSS Statistics 18.0 for Windows was used to analyze data using the procedures of descriptive, frequency, parametric (t-test) and correlation analysis, and text analysis method was used to analyze the quantitative data.Main Results and Findings1. New health record was setted up, and in exiting health records, assessment of elderly daily living and health examination form were added;2. ADL scored 17.8±7.42 before heath education indicating slight function decrease. ADL scored 16.1 ±4.77 in follow-up, and t test showed that ADL decrased significantly in follow-up. WHODAS socred 1.6±0.60 indicating slight function barrier, and CFAI socred 51.2±11.96 indicating fraility being below average level;3. Positive correlation was found between physical domin of CFAI scores and overall score of ADL and each domin socre. Positive correlation was found between CFAI overall scores, physical, psychological domin and overall score of WHODAS and each domin socre. Positive correlation was also found between ADL and WHODAS overall socre and most all domins;4. Health needs could be categorized to 3 genera, chronic disease, health care and other health needs. Chronic disease genera included 4 sub- genera, general knowledge, high blood pressure, diabetes and cardia-cerebrovascular disease.Recommendations for Policy Making1. General practitioner team service modeChronic disease control and management by general practitioner team type service to the communty population has positive effect, is new health management mode to reduce disease risk factors from the source, and is the first line of primary health care. The use of community health promotion platform, to understand the impact of disease on patients and possible social, family, personal psychological pressure, psychological guidance in time, reduce stress, reduce the gap between doctors and patients, and increase mutual trust. Family physicians and patients will develop more closely the relationship between doctors and patients, and this team will combine preventive care, health education and chronic disease management together.2. Strengthen the training of community nursesAt present the community nurses strength is weak, the low level of education, professional quality is low, on cardiovascular disease, diabetes, hypertension and other common diseases, diagnosis, treatment and health education guidance could not meet the needs of residents. Now community nursing was not included in communty nursing, hospitals should transport specialist nurses for community health service, provide regular chronic disease nursing service for community residents in time to meet their health needs, mobilize the residents to improve living and diet exercise, and provide professional health management services for the residents.3. By adopting diversified health educationHealth education should be diversified in form, make full use of the characteristics of different forms, according to the current group of type, adopt the form of effective health education. The main form can be effectively carried out in community health service work:the health lecture aims to enable residents to establish a system to impart knowledge, health awareness, to have a correct understanding of chronic disease, establish the disease control confidence, to master the correct method of treatment, compliance with the good life style, to build a knowledge base of self management, thereby effectively the elimination of promoting health risk factors; group discussion, can play the role of peer education, combined with his experience in life, exchange experience and experience; practice makes theory is used in the practical life, the church residents useful skills, so that residents of effective self-management; telephone consultation is the community staff through visit at any time, at any time to grasp accurately, timely detection of problems, timely correct problems process. The establishment of feelings between the residents and visitor, let the residents feel the warm others care, improve the treatment they receive, the implementation of compliance of self management, enhance to conquer the disease letter; health intervention measures of health personalized is due to different degree of development of different diseases, disease control situation is different, treatment options vary, finding the problems in communicate with residents, solve the problem, find the start point, help the patients of community residents to establish individualized diet principles, such as principle of movement, rest time, and to develop improved step by step and the concrete practice, really make health interventions are implemented, the implementation is strong.4. Strengthen health management services meet the needsThe study of health education is carried out by community health service stations, and those come to the community residents basically with self-care ability, but for those with low ability of daily living of poor and chronically ill residents, community nurses as their social communication bridge, through home visit to provide health management services for their chronic disease, according to the different the health status of the residents to carry out to meet their health needs of the health management of chronic disease.5. Strengthen the construction of community health service institutions and funds inputThe government should further vigorously support the development of community health service centers, community health service center to increase capital investment, formulate relevant supporting policies, the full implementation of doctor multi sited licensed, attract general practitioner into the community, medical experts into the community, vigorously promote the hospital community medicine conjoined construction, the implementation of community and hospital inspection results recognition and inspection report instant transmission, diagnosis and treatment of patients get big hospital in community can. Community health education to sustainable development, not only to guarantee policy, at the same time also should vigorously support the government finance. Further improving the quality control mechanism should be conducted, improving funds compensation mechanism, promote the development of health management service from the objective. |
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