Sample chronic disease management work plan, how to develop a chronic disease management plan

Legal Analysis: In order to strengthen the prevention and treatment of chronic diseases, reduce the burden of diseases, increase the healthy life expectancy of residents, and strive to protect people's health in an all-round and full-cycle manner, this plan is formulated in accordance with the "Healthy China 2030" Planning Outline.

Legal basis: Social Insurance Law of the People's Republic of China

Article 4 Employers and individuals within the territory of the People's Republic of China who pay social insurance premiums in accordance with law have the right to inquire about payment records and records of individual rights and interests, and to request social insurance agencies to provide social insurance consultation and other related services.

Individuals enjoy social insurance benefits in accordance with the law, and have the right to supervise their own units' contributions for them.

Article 5: The people at or above the county level shall include social insurance undertakings in their national economic and social development plans.

The state raises social insurance funds through multiple channels. The people at or above the county level shall give necessary financial support to the social insurance undertakings.

The state supports social insurance through preferential tax policies.

(1) Mission objectives

1. Implement the first diagnosis and blood pressure measurement system for community residents over 35 years old; Blood pressure and blood sugar should be measured at least once a year, and chronic disease prevention and treatment work plan should be planned.

2. For newly discovered patients with hypertension and diabetes, it is necessary to establish standardized and complete archives, with a filing rate and standardized management rate of more than 95% and an effective follow-up rate of 85%.

3. The registration rate of hypertension and diabetes should reach 85% and more than 2% for residents over 35 years old in the jurisdiction.

4. The reporting data of hypertension, diabetes, stroke and tumor are accurate, complete and timely.

(2) Specific measures

1. There is a special person responsible for the prevention and treatment of chronic diseases in the community.

2. If a suspected tuberculosis patient is found, he or she shall immediately transfer to the tuberculosis prevention and control institution in the district for further examination, and antituberculosis drugs shall not be prescribed.

3. Implement whole-process supervision for infectious tuberculosis patients, and standardize the medication rate of more than 98%. And promptly instruct the patient to do the necessary examinations and send sputum for re-examination on time, and deal with or report any adverse reactions in time.

4. Implement the first diagnosis and blood pressure measurement for community residents over 20 years old for the registered population, and measure blood pressure and blood sugar at least once a year for residents over 35 years old, and do a good job of periodic physical examination for residents (once a year or once every two years).

5. Master the number of residents with hypertension and diabetes in the jurisdiction, have standardized and complete medical records and register (the registration rate of hypertension is 5%, and the registration rate of diabetes is 2%), and the standardized management and follow-up rate are more than 95%. Quarterly, semi-annual, and year-end evaluations and other work indicators, blood pressure control compliance rate, blood glucose control compliance rate, and individual effect evaluation should all meet the requirements.

6. Master the basic situation of the elderly over 60 years old (permanent population) in the jurisdiction and have a roster, health records and other complete information, carry out periodic physical examination of the elderly, and have work records and information.

7. Supervise visits to key groups as required, and keep records.

8. In accordance with the requirements of chronic disease prevention and control, timely, accurately, completely and standardly, the original data related to the prevention and treatment of chronic diseases shall be counted into reports and reported on time.

9. According to the needs of the prevention and treatment of various chronic diseases, actively carry out the corresponding chronic disease prevention and treatment, health education and health promotion work.

Legal analysis: The outpatient medical expenses incurred by urban employees with Class A chronic diseases shall be paid by 85% of the overall planning**. The cost of outpatient hemodialysis, peritoneal dialysis and cyclosporine A after organ transplantation for patients with chronic renal failure (renal failure) will be increased by 10%; The annual minimum payment line for Class B chronic diseases is 300 yuan (there is no minimum payment line for mental disorders caused by epilepsy and mental retardation accompanied by mental disorders).

The outpatient medical expenses incurred by patients with chronic diseases in Category B shall be paid at 80% above the threshold standard, and the maximum payment limit for chronic diseases shall not be exceeded in one medical year.

Legal basis: Social Insurance Law of the People's Republic of China Article 26 The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with national regulations.

Chronic disease management includes early screening of chronic diseases, chronic disease risk**, early warning and comprehensive intervention, as well as comprehensive management of chronic disease populations, and evaluation of chronic disease management effects.

Chronic disease management refers to the medical behavior and process of regular detection, continuous monitoring, evaluation and comprehensive intervention management of chronic non-communicable diseases and their risk factors.

The term health management has appeared in China for about 10 years, and with the emergence of health examination institutions, the concept of health management has gradually spread. However, the early examination center only intercepts one or several links of the health management service system, and does not really realize the value of health management services. At present, many health service institutions (mainly community health service centers) in China have carried out health management services with the goal of improving the quality of life of patients and reducing medical costs while treating existing diseases.

The object of chronic disease management is the phenomenon that the behaviors and actions of chronic disease management are directly directed to and want to change. In essence, the object of chronic disease management is an artificially delineated scope, which indicates "what to manage, no matter what", so the demarcation of chronic disease management objects not only leads the direction of chronic disease management, but also determines the success or failure of chronic disease management.

Judging from the current policy regulations, the management target of chronic diseases is "chronic non-communicable diseases". According to the published research report on the practice of chronic disease management, the target of chronic disease management is not only "chronic non-communicable diseases", but also the "cognition, behavior, and motivation" of patients with "chronic non-communicable diseases". Rock cherry birds.