对慢性病管理中存在问题有哪些?

Problems in the management of chronic diseases

群众自我保健意识薄弱对慢病危害认识不到位，导致对慢病将会给人们未来健康带来的危害认识不足，使得社区慢病防控工作难以开展实行。目前社区慢病防控工作所需经费完全靠政府等上级部门拨款，而每年对慢病防控工作的资金常用于针对几种主要慢病与导致慢病危害因素的管理与干预，资金渠道的缺失也导致社区慢病防控工作难以开展。

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.

人员配置不足，人员问题严重制约慢病管理工作的顺利开展，基层从事慢病管理的人员少，慢病管理现状多为一人多职，多数工作人员兼顾老年人管理居民建档重病患者管理慢病管理等。人员不足制约着慢病管理工作的顺利开展。

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.

各级医疗机构在慢病管理上的双向转诊制度不完善，未建立良好的运作机制，导致上下级医疗机构衔接责任不明确，影响着慢病管理工作的正常开展。

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.

二对策

II. Countermeasures

加强健康教育和健康促进活动。各社区卫生服务中心应设置慢病防治知识宣传栏，介绍慢病危害性及防治措施。对社区内人员进行慢病防治知识普及，发放宣传手册，介绍慢病危害及防治措施。并在社区内开设咨询点，为患者解答慢病的防控防治疑虑，定期举办慢病知识讲座，提倡良好生活习惯建立健康生活方式。

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.

建立完善的上下级医院转诊制度，包含健全的上下级定点医院转诊制度，建立专职机构，负责连接上级医疗机构与社区卫生服务中心的双向转诊。同时规范管理，建立系统的转诊程序，做到可落地，形成良好的运行机制。

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.

做好技能培训，应做好公卫人员慢病管理流程及工作思路建立的培训，加强公卫人员及临床人员慢病诊断 随访等基础工作的技能培训，由上级条件较好且经验丰富的医疗机构对下级医疗机构人员进行培训。

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.

建立上下级医疗机构筛查机制，对35岁以上初诊病人首诊测血压，测血糖的制定进行筛查，提高慢病筛查的真实性，根据门诊住院筛查的病例情况，将高危人群妥善完善信息资料登记，做好随访工作。

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.

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