Medical institutions can adopt a set of professional chronic disease specialist follow-up+Kangce AI artificial intelligence follow-up system. Through interfacing with the HIS system, they can conduct hierarchical follow-up management for archived outpatient and discharged patients, achieving accurate follow-up. Various roles in the community can accurately intervene and assist patients with poor disease control based on the patient's situation. The worse the patient's disease management, the stronger the intervention method and frequency. At the same time, long-term tracking of patients' behavior after receiving intervention is conducted through the system to ensure that cognitive education for patients can be translated into actual behavioral changes, and ultimately drive the disease to develop for the better.

漫長康復過程中的“同伴互助”也非常重要。在數字化患者管理新服務模式中，實際有兩大核心能力：一是短時間內讓患者有自我管理的能力，這個能力可以伴隨終身；二是陪伴患者漫長的病程里，讓他們的問題有人解答，與疾病相處的過程中有同伴。針對此，通過基于企微微信的社群會不定期邀請患者中的康復患者分享經驗，用榜樣的力量幫助患者樹立信心。

"Peer assistance" during the long rehabilitation process is also very important. In the new service model of digital patient management, there are actually two core competencies: one is to provide patients with the ability to manage themselves in a short period of time, which can accompany them for a lifetime; The second is to accompany patients during the long course of their illness, allowing them to have their questions answered, and to have companions during their interactions with the disease. In response, through the WeChat based community, rehabilitation patients among patients are invited to share their experiences from time to time, using the power of example to help patients build confidence.

為了防治慢性病，降低居民負擔，提高期望壽命，國務院印發了《防治慢性病中長期規劃(2017-2025)》，《規劃》提出，堅持預防為主，加強行為和壞境危險因素控制，強化慢性病早篩查和早發現，推動由疾病治療向健康管理轉變。《規劃》目標是，到2020年和2025年，力爭30-70歲人群因心腦血管疾病、癌癥、慢性呼吸系統疾病和糖尿病導致的過早死亡率分別較2015年降低10%和20%。

In order to prevent and treat chronic diseases, reduce the burden on residents, and improve life expectancy, the State Council has issued the "Medium and Long Term Plan for the Prevention and Treatment of Chronic Diseases (2017-2025)", which proposes to adhere to prevention first, strengthen the control of behavioral and environmental risk factors, strengthen early screening and detection of chronic diseases, and promote the transition from disease treatment to health management. The Plan aims to reduce the premature mortality rate of 30-70 year olds due to cardiovascular and cerebrovascular diseases, cancer, chronic respiratory diseases and diabetes by 10% and 20% respectively from 2015 by 2020 and 2025.

基礎醫療參與慢病管理的最大優勢是可以與治療的整個流程結合得更為緊密。線下教練的優勢是可以更細致地通過運動、飲食、生活方式指導去改變用戶的生活狀態，促進慢病治療。采用“基礎醫療+線下教練+社群分享”的新服務模式，讓醫療服務更有溫度，讓患者讓有獲得感。

The biggest advantage of basic medical care participating in chronic disease management is that it can be more closely integrated with the entire process of treatment. The advantage of offline coaches is that they can more carefully guide users through exercise, diet, and lifestyle to change their living conditions and promote the treatment of chronic diseases. The new service model of "basic medical care+offline coaches+community sharing" is adopted to make medical services more warm and provide patients with a sense of gain.