Health management of patients with chronic diseases
service object
Patients with essential hypertension and type 2 diabetes in permanent residents aged 35 and above
service content
（1） Screening
For residents aged 35 and above in the jurisdiction, their blood pressure is measured every year when they first visit the hospital or community health service center (station).
If the blood pressure is higher than normal three times on the same day, it can be preliminarily diagnosed as hypertension. It is recommended to refer to a qualified superior hospital for diagnosis and obtain a treatment plan, follow up the results of the referral within 2 weeks, and include the confirmed primary hypertension patients into the health management of hypertension patients.
It is recommended that the blood pressure of high-risk groups (high blood pressure, overweight and obesity, high-salt diet, family history of hypertension, long-term excessive drinking, age greater than 55) be measured at least once every six months, and receive the lifestyle guidance of medical staff.
Targeted health education should be carried out for the high-risk group of type 2 diabetes found in the work, and it is recommended that they measure fasting blood glucose at least once a year, and receive health guidance from medical personnel.
（2） Follow-up evaluation
For patients with essential hypertension, face-to-face follow-up should be provided at least four times a year (once a quarter).
For diagnosed type 2 diabetes patients, four free fasting blood glucose tests are provided every year, and at least four face-to-face visits (once a quarter) are conducted.
（3） Classified intervention
(1) Patients who are satisfied with the control of blood pressure or blood sugar, have no adverse drug reactions, no new complications or no aggravation of the original complications, should make an appointment for the next follow-up.
(2) For patients with unsatisfactory control of blood pressure or fasting blood glucose for the first time, or adverse drug reactions, guidance should be given in combination with their medication compliance. If necessary, increase the existing drug dose, replace or add different types of antihypertensive or hypoglycemic drugs, and follow up within 2 weeks.
(3) For patients who are not satisfied with the control of blood pressure or fasting blood glucose for two consecutive times, or whose adverse drug reactions are difficult to control, and who have new complications or aggravation of the original complications, it is recommended that they should be referred to a superior hospital and actively follow up the referral within two weeks.
(4) Carry out targeted health education for all patients with hypertension and diabetes, work with patients to develop lifestyle improvement goals and assess progress at the next follow-up. Tell the patient what abnormalities should be seen immediately.
（4） Physical examination
For patients with primary hypertension and type 2 diabetes, a health examination is conducted once a year, which can be combined with follow-up. For details, please refer to the health examination form in the Service Specification for Resident Health Archives Management.
