Application Of Chronic Care Model In Community Chronic Disease Management

Ⅰ.Objectives:The purpose of this study was to introduce foreign advanced management of chronic diseases, explore improvement of community management of chronic diseases, and evaluate the effective of Chronic Care Model in community chronic disease management.Ⅱ.Methods:1. Literature ResearchReviewed the literatures related to the Chronic Care Model, and introduced the application of the Chronic Care Model.2. Practical Research(1)Select subjects:300 diagnosis patients over 18 years old with hypertension and diabetes, and has managed more than 1 year were invited in this survey.(2)Experimental control study was used in this study. Two questionnaire surveys were carried out. The study subjects completed questionnaires about the quality of life, general sicken situation, and clinical testing in September 2009. Then, intervention measures according to the Chronic Care Model were designed for test group, after 9 months’ intervention, the study subjects completed clinical testing and the same questionnaires.(3)Epidata 3.1 was used for data entry. Descriptive statistics, t-test,χ2-test, nonparametric tests and other methods were used for data analysis by SPSS 16.0 for Windows. Ⅲ.Results:1. Hypertension patients(1) Diagnostic indicators:The control group and test group had no significant change in systolic blood pressure, diastolic blood pressure were decreased, but the difference of diastolic blood pressure before and after between the two groups had no significant differences.(2) Risk factors:The daily use of salt in two groups had reduced. The proportions of patients with regular alcohol consumption were significantly reduced in the test group. The proportions of patients with smoking in both groups were very low, no significant change was observed. Body mass index (BMI) had reduced significantly in the test group. The waist circumference did not have the remarkable change. According to the Working Group on Obesity in China recommended standards, the proportions of patients with standard waist circumference increased significantly in the test group.(3) Quality of Life:Differences of the SF-36 domains of vitality and the EQ-5D index scores between two measurements had significant difference between two groups. Scores in test group reduced obviously.2. Diabetes:(1) Diagnostic indicators:GLU had reduced significantly in the both group. But the difference of GLU had no statistically significant between two groups. A marked decline in HbAlc was observed in the test group.(2) Risk factors:The proportions of patients with regular alcohol consumption were significantly reduced in the test group. In eating habits, the proportions of patients with light diet were increased significantly. Waist circumference had reduced significantly, and the proportions of patients with standard waist circumference also increased significantly in the test group. Times of patients take part in physical activities a week increased in test group.(3) Quality of Life:Scores of the SF-36 domains of physical functioning, role-physical, social functioning, mental health and physical component summary in test group were higher than control group.Ⅳ.Conclusion:The Chronic Care Model emphasis on the guiding and monitoring role of doctors and the interaction between doctors and patients. The Chronic Care Model was effective in weight loss, waist circumference control and improving drinking habits for Hypertension and Diabetes patients. For Diabetes, it could decline HbAlc and improve the diet and exercise habits. But The Chronic Care Model in the role of blood pressure and blood lipids control need more time for interventions.