Health Management Of Patients With Chronic Diseases
The service object
Patients with primary hypertension and type 2 diabetes among the permanent residents aged 35 or above in the jurisdiction
The service content
For the resident residents aged 35 or above in the jurisdiction, blood pressure shall be measured every year when they go to the hospital or community health service center (station) for the first time.
Blood pressure was higher than normal three times on the same day, which could be preliminarily diagnosed as hypertension. It is suggested that patients should be referred to the competent hospital for diagnosis and treatment, and the results of referral should be followed up within 2 weeks. Patients with diagnosed essential hypertension should be included in the health management of hypertension patients.
It is recommended that high-risk groups (high blood pressure, overweight and obesity, high-salt diet, family history of hypertension, long-term excessive drinking, age over 55 years old) should have their blood pressure measured at least once every six months and receive lifestyle guidance from medical staff.
Targeted health education should be conducted for the high-risk group of type 2 diabetes found in work, and it is suggested that they should measure fasting blood glucose at least once a year and receive health guidance from medical staff.
(II) follow-up evaluation
For patients with essential hypertension, face-to-face follow-up should be provided at least 4 times per year (1 time per quarter).
For diagnosed type 2 diabetes patients, free fasting glucose testing was provided 4 times per year and face-to-face follow-up was conducted at least 4 times (once per quarter).
(III) classified intervention
(1) patients who are satisfied with the control of blood pressure or blood glucose and have no adverse drug reactions, new complications or aggravation of existing complications should be scheduled for the next follow-up.
(2) for patients who are dissatisfied with their first blood pressure or fasting blood glucose control, or have adverse drug reactions, guidance should be given in combination with their medication compliance. If necessary, increase the dose of existing drugs, change or increase different antihypertensive or hypoglycemic drugs, and follow up within 2 weeks.
(3) patients with two consecutive cases of unsatisfactory blood pressure or fasting glucose control, difficult control of adverse drug reactions, and new or worsening complications are recommended to be referred to the superior hospital for active follow-up within 2 weeks.
(4) carry out targeted health education for all patients with hypertension and diabetes, set lifestyle improvement goals together with patients, and evaluate the progress at the next follow-up. Tell patients what abnormalities should be seen immediately.
(IV) physical examination
For patients with essential hypertension and type 2 diabetes, a comprehensive health examination should be conducted once a year, which can be combined with follow-up. The specific contents shall refer to the health inspection form of residents' health records management service standard.