1) Risk factor discovery

根據《全國慢性病預防控制工作規范（試行）2011版》第四章“干預與管理”中指出：慢性病高風險人群為具有以下特征之一者：

According to Chapter 4 "Intervention and Management" of the "National Norms for Chronic Disease Prevention and Control (Trial) 2011 Edition", it is pointed out that high-risk individuals with chronic diseases are those with one of the following characteristics:

（1）血壓水平為130-139/85-89mmHg；

(1) The blood pressure level is 130-139/85-89mHg;

（2）現在吸煙者；

(2) Current smokers;

（3）空腹血糖水平為：6.1 ≤ FBG<7.0mmol/L；

(3) The fasting blood glucose level is 6.1 ≤ FBG<7.0mmol/L;

（4）血清總膽固醇水平為：5.2 ≤ TC<6.2mmol/L；

(4) The serum total cholesterol level is 5.2 ≤ TC<6.2mmol/L;

（5）男性腰圍≥ 90cm，女性腰圍≥ 85cm。

(5) Male waist circumference ≥ 90cm, female waist circumference ≥ 85cm.

針對具有3 項及以上特征者，應當納入個體健康管理范圍

Individuals with three or more characteristics should be included in the scope of individual health management

2) 慢病監測與管理

2) Chronic disease monitoring and management

社區衛生服務中心（站）都在開展以“高血壓”、“糖尿病”、“冠心病”、“腦卒中”、“惡性腫瘤”為重點的慢病性規范化管理工作，“健康小屋”的建設應能對這部分重點人群提供規范化管理的輔助作用，比如定期的高血壓測量、血糖測量有助于及時掌握高血壓患者、糖尿病患者控制效果，及時發現并進行指導。

Community health service centers (stations) are carrying out the standardized management of chronic diseases focusing on "hypertension", "diabetes", "coronary heart disease", "stroke", and "malignant tumor". The construction of the "health house" should be able to provide the auxiliary role of standardized management for this part of the key population. For example, regular measurement of hypertension and blood sugar will help to timely grasp the control effect of hypertension patients and diabetes patients, Timely discovery and guidance.

3) 健康評估與指導

3) Health assessment and guidance

健康管理不同于疾病管理，健康管理主要是根據目前身體狀況，發現危險因素，綜合當前生活方式，進行綜合的評估，并做出健康促進指導，做到早期防預治未病為主。從“合理膳食、適量運行、戒煙戒酒、心理平衡、健康養生”等預防控制健康基石入手。

Health management is different from disease management. Health management is mainly based on the current physical condition, identifying risk factors, integrating the current lifestyle, conducting comprehensive assessments, and providing health promotion guidance to achieve early prevention, treatment, and prevention of diseases. Starting from the cornerstone of prevention and control of health, such as "reasonable diet, moderate exercise, smoking and alcohol cessation, psychological balance, and health preservation".

4) 公共衛生服務

4) Public health services

社區可以通過健康小屋的建設，可以提高國家基礎公共衛生服務的質量，主要體現在“居民日常健康體檢”、“疾病篩查統計”、“慢性病防控”“康復輔助”、“健康教育”、“健康咨詢”、“健康管理服務”。

The construction of health huts in communities can improve the quality of national basic public health services, mainly reflected in "daily health examinations for residents", "disease screening statistics", "chronic disease prevention and control", "rehabilitation assistance", "health education", "health consultation", and "health management services".

四、健康小屋服務流程

4、 Health Cabin Service Process

1) 通過在基層醫療衛生服務機構、居委會、街道辦等公共服務點，部署智能體檢機，采集居民的健康體征數據（身高、體重、血壓、脈率、BMI等），自動傳輸至居民健康管理信息平臺（區域衛生信息系統平臺），推送至社區醫（家庭醫生）的工作平臺。

1) By deploying intelligent physical examination machines at public service points such as grassroots medical and health service institutions, neighborhood committees, and street offices, residents' health sign data (height, weight, blood pressure, pulse rate, BMI, etc.) is collected and automatically transmitted to the residents' health management information platform (regional health information system platform), and pushed to the work platform of community doctors (family doctors).

2) 體檢時，向居民和社區管理者發出健康異常指標提示。

2) During the physical examination, issue health abnormality indicators to residents and community managers.

3) 社區醫生查閱居民的健康體征測量數據，提供相應健康指導。可結合信息平臺轉發至居民個人、居民家屬，告知健康狀況。

3) Community doctors consult residents' health sign measurement data and provide corresponding health guidance. It can be forwarded to individual residents and their families through information platforms to inform them of their health status.

4) 居民個人、居民家屬可登錄相應的健康信息平臺查閱個人的體征測量數據及健康指導建議。

4) Individuals and family members of residents can log in to the corresponding health information platform to view their physical sign measurement data and health guidance suggestions.

5) 平臺與區域的健康檔案系統對接，補充居民的健康檔案。

5) The platform interfaces with the regional health record system to supplement residents' health records.

6) 區域管理者根據信息平臺數據，知曉區域內居民健康信息狀況，為公共衛生服務提供業務數據。

6) Regional managers are informed of the health information status of residents in the region based on information platform data, and provide business data for public health services.

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