Chronic Disease Management Committee

The core value of the Chronic Disease Management Committee has never been an empty organization hanging on the hospital bulletin board, but a practical hub that breaks through the barriers of patients, clinical, public health, and medical insurance, and puts into practice the empty talk of "chronic diseases require long-term management" for many years. This is my most intuitive feeling after spending 6 years in a community health service center and working with chronic disease management committees in 3 different districts and counties for almost 5 years.

Last week, I accompanied Lao Chen, who suffers from type 2 diabetes and hypertension in the community, to the community to get medicines. Three years ago, he had to get up at 6 a.m. and rush to a tertiary hospital to get a prescription. He spent a whole morning to get enough medicines for half a month. Now he goes to the community clinic to swipe his ID card and get three months' worth of medicines in 10 minutes. Before leaving, the health manager gave him an appointment form for a free diabetic foot screening next week. Behind this is the pre-review policy for long prescriptions that our district chronic disease management committee negotiated with the medical insurance department for more than half a year. This alone has saved more than 8,000 chronic disease patients in the district who need long-term medication from making more than 20 trips to the hospital a year.

As for how the Slow Management Committee should run, there has never been a unified standard answer in the industry, and it has even been divided into two completely different schools. In the early years, I came into contact with a chronic management committee led by the District People's Hospital. It is a typical "clinical-oriented" group, and its core resources are tilted towards the clinical side. Last year, it conducted free fundus screening for more than 2,100 diabetic patients in the area, and screened out 32 patients with early retinopathy. They went directly to the ophthalmology department through the green channel for laser intervention, and no one was delayed to the point of visual impairment. However, the shortcomings of this model are also obvious: doctors only screen for diseases and adjust medicines, but have no control over the patients' lives after discharge. Many people still eat pickles, porridge, and braised pork every meal after the screening. Whether their blood sugar should rise or fall, they still think you are nosy when they call for follow-up.

I originally thought that clinical leadership was the right path. It wasn’t until I stayed at a community health service center in a suburban county for three months last year that I discovered that the logic of the “public health leadership” also has irreplaceable value. The Chronic Disease Management Committee there is led by the Centers for Disease Control and Prevention, and is staffed mostly by public health physicians and community health managers. It does not have that many high-end medical resources, so it spends its days in the community dealing with the uncles and aunts. It holds health lectures every week, distributes salt control spoons and oil-limiting cans to every household, and organizes a walking group for patients with chronic diseases. They walk around the park for 40 minutes every night, and some people are watching to prevent them from secretly buying fried skewers on the roadside. But there is also a problem: when a patient's blood sugar suddenly spikes, the dose of antihypertensive medication needs to be adjusted, or there are suspicious signs of complications, they are not qualified to handle it, so they can only issue a referral order to send the patient to a large hospital. Many people find it troublesome and delay the visit, which eventually becomes a big problem.

There are also some that combine the two very well. The Chronic Disease Management Committee in the next district has half clinical staff and half public health staff. It also specially recruits staff from two medical insurance bureaus to work. When I went to study last month, they had just launched a "chronic disease point system": 5 points are added for measuring blood pressure and blood sugar on time and uploading data, 10 points are added for attending health lectures, 30 points are added for taking medicine according to doctor's orders for 3 consecutive months and not stopping medicine without permission. The points can be exchanged for free physical examination items, and can also be used to offset out-of-pocket expenses for outpatient registration and medicine. Data at the end of last year showed that the standard management rate of hypertension in their jurisdiction increased from 41.8% to 67.2%, and the incidence of diabetes complications dropped by 12 percentage points. The results are real.

Speaking of which, we have encountered many pitfalls before as a chronic management committee. In the past two years, we followed the trend of digital management and issued smart blood pressure bracelets to every patient with chronic diseases, requiring automatic uploading of data every day. As a result, half of the adults did not know how to connect to Bluetooth, and some found it too troublesome to charge every day, so they just threw the bracelets in the drawer to collect dust. The data pass rate in the background was not even 30%. Later, adjustments were made quickly, and young and middle-aged patients who were willing to use smart devices went through the digital channel, while the elderly still retained the traditional model of weekly community free clinics and monthly visits by specialists for follow-up visits. The data qualification rate suddenly climbed to more than 90%.

Many people don't understand it. They think that the Slow Management Committee is just a sinecure, and it is only for people who have no place to arrange it. This is really not the case. The most dedicated Slow Management Committee commissioner I have ever seen rode an electric bike for more than 20 minutes on a snowy day last winter to go to a village in the city to measure the blood pressure of an elderly person living alone with limited mobility. His trouser legs and shoes were all wet, and he was so cold that he was shaking when he spoke, just to remind the elderly person that the temperature had dropped recently and that he could not reduce the dose of antihypertensive drugs by himself.

In fact, until now, there is no standard answer to the operating model of chronic disease management committees. The population structure, medical resources, and medical insurance policies in different regions are different. If you copy other people's experience, you will probably overturn it. But no matter how the model changes, the core goal has never changed: it is just to help patients with chronic diseases visit the hospital less often, suffer less complications, and spend less money.