慢病管理+智能随访系统打造数字化慢病随访管理系统

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.

漫长康复过程中的“同伴互助”也非常重要。在数字化患者管理新服务模式中，实际有两大核心能力：一是短时间内让患者有自我管理的能力，这个能力可以伴随终身；二是陪伴患者漫长的病程里，让他们的问题有人解答，与疾病相处的过程中有同伴。针对此，通过基于企微微信的社群会不定期邀请患者中的康复患者分享经验，用榜样的力量帮助患者树立信心。

"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.

为了防治慢性病，降低居民负担，提高期望寿命，国务院印发了《防治慢性病中长期规划(2017-2025)》，《规划》提出，坚持预防为主，加强行为和坏境危险因素控制，强化慢性病早筛查和早发现，推动由疾病治疗向健康管理转变。《规划》目标是，到2020年和2025年，力争30-70岁人群因心脑血管疾病、癌症、慢性呼吸系统疾病和糖尿病导致的过早死亡率分别较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.

基础医疗参与慢病管理的最大优势是可以与治疗的整个流程结合得更为紧密。线下教练的优势是可以更细致地通过运动、饮食、生活方式指导去改变用户的生活状态，促进慢病治疗。采用“基础医疗+线下教练+社群分享”的新服务模式，让医疗服务更有温度，让患者让有获得感。

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.