Problems in the management of chronic diseases

群眾自我保健意識薄弱對慢病危害認識不到位，導致對慢病將會給人們未來健康帶來的危害認識不足，使得社區慢病防控工作難以開展實行。目前社區慢病防控工作所需經費完全靠國家政府等上級部門撥款，而每年國家對慢病防控工作的資金常用于針對幾種主要慢病與導致慢病危害因素的管理與干預，資金渠道的缺失也導致社區慢病防控工作難以開展。

The public's weak awareness of self health care and inadequate understanding of the hazards of chronic diseases have led to a lack of understanding of the hazards that chronic diseases will bring to people's future health, making it difficult to carry out community chronic disease prevention and control work. At present, the funds required for community chronic disease prevention and control work are entirely funded by the national government and other higher-level departments, and the annual funding for chronic disease prevention and control work is often used to manage and intervene in several major chronic diseases and factors that lead to chronic disease hazards. The lack of funding channels also makes it difficult to carry out community chronic disease prevention and control work.

人員配置不足，人員問題嚴重制約慢病管理工作的順利開展，基層從事慢病管理專業的人員少，慢病管理現狀多為一人多職，多數工作人員兼顧老年人管理居民建檔重病患者管理慢病管理等。人員不足制約著慢病管理工作的順利開展。

Insufficient personnel allocation and serious personnel issues have hindered the smooth implementation of chronic disease management work. There are few grassroots professionals engaged in chronic disease management, and the current situation of chronic disease management is mostly one person with multiple positions. Most staff members also take care of elderly management, resident filing, and chronic disease patient management. The shortage of personnel restricts the smooth implementation of chronic disease management work.

各級醫療機構在慢病管理上的雙向轉診制度不完善，未建立良好的運作機制，導致上下級醫療機構銜接責任不明確，影響著慢病管理工作的正常開展。

The two-way referral system for chronic disease management in medical institutions at all levels is not perfect, and a good operating mechanism has not been established, resulting in unclear responsibilities for the connection between upper and lower levels of medical institutions, which affects the normal development of chronic disease management work.

二對策

II. Countermeasures

加強健康教育和健康促進活動。各社區衛生服務中心應設置慢病防治知識宣傳欄，介紹慢病危害性及防治措施。對社區內人員進行慢病防治知識普及，發放宣傳手冊，重點介紹慢病危害及防治措施。并在社區內開設咨詢點，為患者解答慢病的防控防治疑慮，定期舉辦慢病知識講座，提倡良好生活習慣建立健康生活方式。

Strengthen health education and health promotion activities. Each community health service center should set up a bulletin board on chronic disease prevention and control knowledge, introducing the hazards and prevention measures of chronic diseases. Popularize knowledge on chronic disease prevention and control among community personnel, distribute promotional manuals, and focus on introducing the hazards and prevention measures of chronic diseases. And establish consultation points in the community to answer patients' concerns about the prevention, control, and prevention of chronic diseases, regularly hold lectures on chronic disease knowledge, and promote good habits and healthy lifestyles.

建立完善的上下級醫院轉診制度，包含健全的上下級定點醫院轉診制度，建立專職機構，負責連接上級醫療機構與社區衛生服務中心的雙向轉診。同時規范管理，建立系統的轉診程序，做到可落地，形成良好的運行機制。

Establish a sound referral system for upper and lower level hospitals, including a sound referral system for upper and lower level designated hospitals, and establish a dedicated institution responsible for connecting higher-level medical institutions with community health service centers for two-way referral. At the same time, standardize management, establish a systematic referral procedure, achieve practicality, and form a good operating mechanism.

做好技能培訓，首先應做好公衛人員慢病管理流程及工作思路建立的培訓，加強公衛人員及臨床人員慢病診斷治療 隨訪等基礎工作的技能培訓，由上級條件較好且經驗豐富的醫療機構對下級醫療機構人員進行培訓。

To do a good job in skill training, the first step is to provide training on the establishment of chronic disease management processes and work ideas for public health personnel, strengthen the skill training for basic work such as diagnosis, treatment, and follow-up of chronic diseases for public health personnel and clinical personnel, and have superior and experienced medical institutions provide training for lower level medical institution personnel.

建立上下級醫療機構篩查機制，對35歲以上初診病人首診測血壓，測血糖的制定進行篩查，提高慢病篩查的真實性，根據門診住院篩查的病例情況，將高危人群妥善完善信息資料登記，做好隨訪工作。

Establish a screening mechanism for upper and lower level medical institutions to screen the development of blood pressure and blood sugar measurements for first-time patients aged 35 and above, improve the authenticity of chronic disease screening, and properly register high-risk groups with information and data based on the case situation of outpatient and inpatient screening, and carry out follow-up work.

本文由慢病隨訪管理系統友情奉獻.更多有關的知識請點擊: http://www.120dhyy.cn真誠的態度.為您提供為全面的服務.更多有關的知識我們將會陸續向大家奉獻.敬請期待

This article is dedicated by the Chronic Disease Follow up Management System. For more information, please click on: http://www.120dhyy.cn Sincere attitude. We will provide you with comprehensive services. We will gradually contribute more relevant knowledge to everyone. Stay tuned