Model and pathway for building an integrated chronic non-communicable disease management and rehabilitation system
In order to achieve the goal of"comprehensive,full-process,full-cycle",the national chronic disease health management and rehabilitation goals need to promote the integration of health resources,engage multiple stakeholders in collaborative governance,and explore new models for chronic disease management and rehabilitation.This will make the chronic disease management and rehabilitation system more effectively compatible with current medical services and health management systems.This article draws on domestic and international experiences in chronic disease management,summarizes the problems of chronic disease management in China's approach,and considers the path of"hospital-community-family"pathway through a literature review.By integrating various medical resources and initiating multidisciplinary team collaboration,we aim to construct a layered and tiered integrated chronic disease management and rehabilitation system based on the"Four Threes"framework.This model can make full use of digital technology to provide health management for patients with chronic diseases,realizing a new integrated model of chronic disease management throughout the entire lifecycle of chronic disease patients,establishing a new paradigm of integrated chronic disease management where community-based care,home-based self-care,and hospital-led treatment are effectively coordinated.It offers support for chronic disease management and rehabilitation at both individual and societal levels.
Chronic disease management and rehabilitation systemMultidisciplinary tiered integrationIntegrated model
NETL
NSTL
万方数据
