Chronic Disease Management Model Research Articles

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation.

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. Average of n=631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72hours of hospital discharge. Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β=0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β=-0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β=-0.37; 95% CI, -0.66 to -0.07). In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

A randomized multicenter trial of a chronic disease management intervention for decompensated cirrhosis. The Australian Liver Failure (ALFIE) trial

Background and aims: Improving the care of decompensated cirrhosis (DC) is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). Secondary aims were to assess model effects on quality-of-care and patient reported outcomes. Approach and results: Study design was a two-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a DC admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. 147 participants (Intervention=75, Control=71) were recruited with a median MELD score of 19. For the primary outcome, there was no difference in the overall LREA rate for the Intervention group versus Control group (IRR 0.89; 95% CI 0.53-1.50, p=0.666) or in actuarial survival (HR=1.14; 95% CI 0.66-1.96, p=0.646). However, there was a reduced risk of LREA due to encephalopathy in the Intervention versus Control group (Hazard ratio=1.87; 95% CI 1.18-2.96, p=0.007). Significant improvement in quality-of-care measures was seen for performance of bone density (p=<0.001), vitamin D testing (p=<0.001) and HCC surveillance adherence (p=0.050). For assessable participants (44/74 Intervention, 32/71 Controls) significant improvements in patient-reported outcomes at 3 months were seen for self-management ability and quality of life as assessed by visual analog scale (p=0.044). Conclusions: This CDM intervention did not reduce overall LREA events and may not be effective in DC for this endpoint.

Application of E-coach chronic disease management model in rehabilitation management of patients with arteriosclerosis obliterans

ObjectiveTo explore the effect of a health (E)-coach chronic disease management model on the rehabilitation behaviour management of patients with arteriosclerosis obliterans (ASO).MethodsThe E-coach chronic disease management model was constructed based on a literature review and expert interviews. The effect of the E-coach model on patients with ASO during hospitalisation was analysed by comparing the compliance rates of blood glucose control, blood pressure control, drug compliance, ankle-brachial index, 6-min walking test (6MWT) and pain-free walking distance (PFWD) scores between the E-coach and control groups.ResultsIn total, 212 patients with ASO were included in this study. After the intervention, the blood pressure compliance rate (44.8% vs. 65.7%) and blood glucose compliance rate (48.6% vs. 66.8%) were higher in the E-coach group than in the control group (p < 0.05). After intervention, compared with the control group, the patients in the E-coach group had better drug compliance (6.8 ± 1.9 vs. 7.9 ± 1.0), and the difference was statistically significant (p < 0.05). The scores for the 6MWT (329.19 ± 5.58 vs. 353.00 ± 9.76; 412.65 ± 12.59 vs. 499.16 ± 18.43) and PFWD (219.15 ± 11.96 vs. 225.36 ± 16.13; 331.62 ± 51.36 vs. 369.42 ± 75.71) tests were significantly higher in the E-coach group than in the control group at 1 and 6 months after intervention (p < 0.05).ConclusionThe E-coach chronic disease management model can effectively improve the control rates of blood glucose and blood pressure and the behaviour management of patients with ASO and is thus worthy of clinical reference.

Patient perceptions about obesity management in the context of concomitant care for other chronic diseases

BackgroundApproximately 15% of Canadian adults live with two or more chronic diseases, many of which are obesity related. The degree to which Canadian obesity treatment guidelines are integrated into chronic disease management is unknown. MethodsWe conducted a 12-min online survey among a non-probability sample of 2506 adult Canadians who met at least one of the following criteria: 1) BMI ≥30 kg/m2; 2) medical diagnosis of obesity; 3) undergone medically supervised treatment for obesity; or 4) a belief that excess/abnormal adipose tissue impairs their health. Participants must have been diagnosed with at least one of 12 prevalent obesity-related chronic diseases. Data analysis consisted of descriptive statistics. ResultsOne in four (26.4%) reported a diagnosis of obesity, but only 9.2% said they had received medically supervised obesity treatment. The majority (55%) agreed obesity makes managing their other chronic diseases challenging; 39% agreed their chronic disease(s) have progressed or gotten worse because of their obesity. While over half (54%) reported being aware that obesity is classified as a chronic disease, 78% responded obesity was their responsibility to manage on their own. Only 33% of respondents responded they have had success with obesity treatment. InterpretationWhile awareness of obesity as a chronic disease is increasing, obesity care within the context of a wider chronic disease management model is suboptimal. More work remains to be done to make Canadian obesity guidelines standard for obesity care.

Patient Education with New Media Integration Self-Management Support Model Improves Therapeutic Outcomes of Rosacea Patients.

To retrospectively analyze the factors influencing the treatment of rosacea patients with regular follow-up by self-management support in the new media chronic disease management model, to explore the effect of self-management support and to provide an objective basis for clinical application. Female patients with rosacea who were regularly followed up for more than 6 months at the rosacea follow-up clinic of the Department of Dermatology, West China Hospital, Sichuan University, from March 2022 to June 2023, with erythema and capillary dilation as the main clinical phenotype, met the rosacea diagnostic criteria of the American Rosacea Expert Committee 2017 edition, and received medications recommended by the Chinese Rosacea Treatment Guidelines (2021 edition). A total of 125 patients were treated with combined photobiomodulation therapy (PBMT), and the patients were divided into a standardized group (CEA<1, IGA<1) and a non-standardized group (CEA≥1, IGA≥1) based on significant rosacea efficacy (CEA<1, IGA<1) within 6 months. The age, gender, education level, duration of rosacea, treatment regimen, education intensity, CEA, and IGA baseline data were compared between the two groups, and logistic regression analysis was performed to analyze the factors influencing the significant efficacy of rosacea. There was a significant difference in the mean length of education between the two groups (P<0.05), and the differences between the rest of the baseline information of the two groups were not statistically significant (P>0.05). Logistic regression analysis showed that the variable that significantly influenced the efficacy of treatment was the mean length of education (≥130.5 min/month), and the intensity of education was significantly associated with the efficacy of treatment. Self-management support in the new media chronic disease management model has a positive impact on the treatment of rosacea patients.

The digitized chronic disease management model: scalable strategies for implementing standardized healthcare and big data analytics in Shanghai.

Chronic disease management (CDM) falls under production relations, and digital technology belongs to the realm of productivity. Production relations must adapt to the development of productivity. Simultaneously, the prevalence and burden of chronic diseases are becoming increasingly severe, leveraging digital technology to innovate chronic disease management model is essential. The model was built to cover experts in a number of fields, including administrative officials, public health experts, information technology staff, clinical experts, general practitioners, nurses, metrologists. Integration of multiple big data platforms such as General Practitioner Contract Platform, Integrated Community Multimorbidity Management System and Municipal and District-Level Health Information Comprehensive Platform. This study fully analyzes the organizational structure, participants, service objects, facilities and equipment, digital technology, operation process, etc., required for new model in the era of big data. Based on information technology, we build Integrated Community Multimorbidity Care Model (ICMCM). This model is based on big data, is driven by "technology + mechanism," and uses digital technology as a tool to achieve the integration of services, technology integration, and data integration, thereby providing patients with comprehensive people-centered services. In order to promote the implementation of the ICMCM, Shanghai has established an integrated chronic disease management information system, clarified the role of each module and institution, and achieved horizontal and vertical integration of data and services. Moreover, we adopt standardized service processes and accurate blood pressure and blood glucose measurement equipment to provide services for patients and upload data in real time. On the basis of Integrated Community Multimorbidity Care Model, a platform and index system have been established, and the platform's multidimensional cross-evaluation and indicators are used for management and visual display. The Integrated Community Multimorbidity Care Model guides chronic disease management in other countries and regions. We have utilized models to achieve a combination of services and management that provide a grip on chronic disease management.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews.

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI). Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021. Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models. Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use). Narrative synthesis, including proportion of reviews documenting outcome benefits. More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease. Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Structure and Function of a Provincial Renal Pharmacy Program: Applying the Chronic Care Model to Address Equitable Access to Medication and Pharmacy Services.

We described the rationale, structure, design, and components of a provincial pharmacy services network for patients with kidney disease as a model for enabling equitable access and universal care to pharmacy services and medications across a wide range of clinical conditions, and geographic expanse in British Columbia (BC). These include minutes from 53 Pharmacy Services and Formulary (PS&F) Committee meetings held from 1999 to November 2022, documentation available on the British Columbia Renal (BCR) website, direct observation and participation in committee meetings, as well as interviews with key individuals involved in different aspects of the program. We reviewed documents and data describing the evolution, rationale, and functioning of the BCR provincial pharmacy services system and used a variety of sources as mentioned above. In addition, a qualitative thematic synthesis of reports of chronic care models (CCMs) was conducted to map the program components into the chronic disease management models. The components of the provincial pharmacy program (PPP) include (1) a PS&F committee, with interdisciplinary and geographical representation; (2) a community of dispensing pharmacies with standardized protocols and information; (3) a dedicated medication and pharmacy services budget, and regular evaluation of budget, outcomes, and performance; (4) provincial contracts for specific medications; (5) communication and education; and (6) information management system. Program components are described in the context of chronic disease management models. The PPP includes dedicated formularies for people with kidney disease at different points in the disease trajectory, including those on and off dialysis. Equitable access to medications is supported across the province. All medications and counseling services are provided to all patients registered in the program, through a robust distributed model, including community- and hospital-based pharmacies. Provincial contracts managed centrally ensure best economic value, and centralized education and accountability structures ensure sustainability. Limitations of the current report include lack of formal evaluation of the program on patient outcomes, but this is relative as the intention of this article is to describe the program which has existed for over 20 years and is fully functional. Formal evaluation of a complex system would include by costs, cost avoidance, provider, and patients' satisfaction. We are developing a formal plan for this reason. The PPP is embedded in the provincial infrastructure of BCR and enables the provision of essential medications and pharmacy services for patients with kidney disease throughout the spectrum. The leveraging of local and provincial resources, knowledge, and expertise to implement a comprehensive PPP, ensures transparency and accountability and may serve as a model for other jurisdictions.

Impact of multidisciplinary chronic disease collaboration management on self-management of hypertension patients: A cohort study.

To explore the effect of the interdisciplinary chronic disease management (CDM) model on patients with hypertension. In this intervention study, the subjects were divided into CDM and control groups. Blood pressure control was monitored in both groups. After 1 year of follow-up, the endpoint events of patients and their knowledge, confidence, and behavior in response to the disease were assessed. When compared with the control group, patients in the CDM group obtained higher scores for self-perception and management assessment, and their blood pressure control was also better after discharge. The quality of life and the satisfaction level of patients in the control group were lower than those in the CDM group, while the unplanned readmission rate, incidence of complications, and the average length of hospital stay in the control group were higher than those in the CDM group. CDM model was beneficial to blood pressure control in hypertensive patients. It had also improved the quality of life and the satisfaction level of the hypertensive patients. Our study highlights the importance of the CDM model in the prognosis of hypertensive patients.

Effectiveness of an integrated primary care intervention in improving psychosocial outcomes among Latino adults with diabetes: the LUNA-D study.

To compare the effectiveness of usual care (UC) versus a culturally tailored integrated care model in improving mental health symptoms for Latino patients with Type 2 diabetes mellitus (T2DM). We conducted a two-arm randomized controlled trial from 2015 to 2019 at a federally qualified health center. Participants were 456 adults ages 23-80 years who had a previous diagnosis of T2DM and were not currently using insulin. Participants were randomly assigned to Integrated Care Intervention (ICI; including behavioral/mental healthcare, medical visits, health education and care coordination) or UC; standard of care including referrals for health education and behavioral/mental health care where appropriate. Intention-to-treat, multilevel models were used to compare group × time changes in depression and anxiety symptoms (PHQ-8; GAD-7) and perceived stress (PSS-10) across 6 months. Participant mean age was 55.7 years, 36.3% were male, and 63.7% were primarily Spanish speaking. Baseline sociodemographic factors and mental health symptoms across study arms were balanced. Significant group × time interaction effects were observed for anxiety and depression symptoms (p < .05). Within the ICI and UC groups, mean depression symptom changes were -0.93 and -0.39 (p < .01); anxiety symptom changes were -0.97 (p < .01) and -0.11 (p = .35); and perceived stress changes were -1.56 and -1.27 (p < .01), respectively. Although both ICI and UC showed decreases over time, the ICI group evidenced larger, statistically significant changes in both depression and anxiety. Adapted integrated models of behavioral and chronic disease management appear to be effective and could be considered for usual care practices. NCT03983499.

Difficult-to-Treat Depression and the Role of Vagus Nerve Stimulation

It has been argued that reconceptualizing treatment-resistant depression as difficult-to-treat depression (DTD) is of both semantic and clinical benefit. Whereas treatment-resistant depression, by definition, most commonly focuses entirely on repeated pharmacological treatment trials, DTD takes a more holistic perspective, considering all treatment modalities — psychotherapeutic, neurostimulatory, psychosocial, self-help, and pharmacological, from a perspective of a chronic disease management model. A key element of the DTD model is frequent reviews of treatment direction, and whether additional options should be considered, including less commonly used treatments, such as implanted vagus nerve stimulation. This selective review considers the potential role of vagus nerve stimulation, both as an acute treatment and for prophylaxis, the implications of previous electroconvulsive therapy response, and the impact of the treatment on quality of life, in the context of the DTD model of care. [ Psychiatr Ann . 2022;52(7):266–271.]

Integration of Artificial Intelligence, Blockchain, and Wearable Technology for Chronic Disease Management: A New Paradigm in Smart Healthcare.

Chronic diseases are a growing concern worldwide, with nearly 25% of adults suffering from one or more chronic health conditions, thus placing a heavy burden on individuals, families, and healthcare systems. With the advent of the “Smart Healthcare” era, a series of cutting-edge technologies has brought new experiences to the management of chronic diseases. Among them, smart wearable technology not only helps people pursue a healthier lifestyle but also provides a continuous flow of healthcare data for disease diagnosis and treatment by actively recording physiological parameters and tracking the metabolic state. However, how to organize and analyze the data to achieve the ultimate goal of improving chronic disease management, in terms of quality of life, patient outcomes, and privacy protection, is an urgent issue that needs to be addressed. Artificial intelligence (AI) can provide intelligent suggestions by analyzing a patient’s physiological data from wearable devices for the diagnosis and treatment of diseases. In addition, blockchain can improve healthcare services by authorizing decentralized data sharing, protecting the privacy of users, providing data empowerment, and ensuring the reliability of data management. Integrating AI, blockchain, and wearable technology could optimize the existing chronic disease management models, with a shift from a hospital-centered model to a patient-centered one. In this paper, we conceptually demonstrate a patient-centric technical framework based on AI, blockchain, and wearable technology and further explore the application of these integrated technologies in chronic disease management. Finally, the shortcomings of this new paradigm and future research directions are also discussed.

Observation of Efficacy of Internet-Based Chronic Disease Management Model Combined with Modified Therapy of Bushenyiliu Decoction in Treating Patients with Type 2 Diabetes Mellitus and Prostate Cancer and Its Effect on Disease Control Rate.

Objective To explore the efficacy of Internet-based chronic disease management model combined with the modified therapy of Bushenyiliu decoction in treating patients with type 2 diabetes mellitus (T2DM) and prostate cancer and its effect on disease control rate (DCR). Methods 120 patients with T2DM and prostate cancer admitted to the Affiliated Hospital of Yangzhou University, Yangzhou First People's Hospital, from February 2019 to February 2020, were retrospectively analyzed and equally divided into the experimental group and the control group according to their admission order. Conventional treatment combined with the modified therapy of Bushenyiliu decoction was performed on all patients for 3 months, and the Internet-based chronic disease management model was adopted for patients in the experimental group additionally, so as to compare their short-term effect, survival time, disease progression, blood glucose indicators, immune function indicators, and type 2 Diabetes Self-Care Scale (2-DSCS) scores. Results Compared with the control group, the experimental group obtained significantly higher DCR and objective remission rate (ORR) (P < 0.05), higher survival time and disease progression (P < 0.001), better blood glucose indicators and immune function indicators (P < 0.001), and higher 2-DSCS scores (P < 0.001) after treatment. Conclusion Combining the Internet-based chronic disease management model with the modified therapy of Bushenyiliu decoction can effectively enhance the self-care ability of patients with T2DM and prostate cancer, improve their blood glucose level, promote their body immunity, and comprehensively optimize the cancer control effect, which should be promoted in practice.

Effect Evaluation of Community Chronic Disease Management Model in Elderly Hypertension Management

Effect Evaluation of Community Chronic Disease Management Model in Elderly Hypertension Management

P0242 - The new chronic lithiasic disease management and risk classification model, based on a Kaiser Permanente Pyramid (KPP) design. The 3-year results

P0242 - The new chronic lithiasic disease management and risk classification model, based on a Kaiser Permanente Pyramid (KPP) design. The 3-year results

Evaluate the Efficacy of Novel Nursing Management Method Including Both Preparation Services and Continuity of Care in Elderly Patients with Aspiration Pneumonia

Objective: The concept of discharge preparation services originated from the continuum of care and referral system first established in the United States in 1910. Extended care is a series of nursing care activities to ensure continuity and coordination of care for patients in different health care settings. Guidance to reduce or prevent the deterioration of the health status of patients with chronic diseases. The aim of our study was to evaluate the efficacy of discharge preparation service and extended care in elderly patients with aspiration pneumonia. Methods: A total of 40 elderly patients with aspiration pneumonia who were hospitalized in the respiratory and critical care department of a tertiary care hospital from February 2017 to February 2019 were enrolled in this study and divided into two groups. Patients in the control group received conventional nursing interventions while patients in observation group received specific chronic disease management including discharge preparation service and continuity of care. Patients' satisfaction with nursing services, their ability to take care of themselves in daily life one month after discharge, and the number of hospital readmissions within one year after discharge were documented and compared between two groups. Results: Our study suggested that patients’ satisfaction with nursing services and their self-care capabilities one month after discharge were significantly higher in the observation group compared to the control group (P<0.05). Meanwhile, the number of readmissions within one year after discharge was significantly decreased in the observation group than in the control group (P<0.05). Conclusion: The chronic disease management model including specific discharge preparation service and extended care provided patients with better nursing services and resulted in better prognosis.

Improved blood pressure control via a novel chronic disease management model of care in sub-Saharan Africa: Real-world program implementation results.

A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community‐partner locations where they received real‐time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the “real‐world” implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (−9.4 mmHg, p < .001) and in the uncontrolled subgroup (−17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment.

Virtual models of chronic disease management: lessons from the experiences of virtual care during the COVID-19 response.

Objective This study examined Gold Coast staff and patient experiences with the rapid expansion of a virtual model of chronic disease management during the COVID-19 pandemic. Methods The study undertook a survey of enrolled patients (n=24) and focus groups with clinical and administrative staff (n=44) delivering chronic disease programs at Gold Coast Health in Queensland. The study also examined routinely collected activity data for the chronic disease programs before COVID (January-February 2020) and for the first 3 months of the COVID-19 response (March-May 2020). Results Chronic disease programs continued to provide similar numbers of appointments over the COVID-19 response period, but there was a marked increase in the proportion of appointments that were delivered virtually, either by telephone or video conference. Most patients were satisfied with their virtual care experiences and felt that their health care needs were met. Conclusions The COVID-19 response provided an opportunity to learn and further develop models of virtual care. Staff and patients were generally supportive of continuing to include virtual appointments in the future. Ongoing concerns were predominantly around the support available to patients and staff to ensure they are trained and equipped to manage the technology and new mode of communicating. What is known about the topic? Emerging evidence suggests that virtual models of health care delivery, such as telephone and video consultations and remote patient monitoring, can be safe and cost-effective alternatives to traditional face-to-face chronic disease management programs. Virtual care is associated with equal or improved clinical outcomes, as well as efficiency improvements, such as reduced failure to attend rates. What does this paper add? The increasing burden of chronic disease across Australia, as well as the need to minimise the risk of vulnerable patient groups attending in-hospital appointments where it is safe and appropriate to do so, means that expanding the delivery of virtual chronic disease management will become increasingly necessary. The results of this study provide an opportunity to learn from a rapid rollout of virtual care for these staff and patient groups and will help inform advances in this area. What are the implications for practitioners? Existing evidence, demographic pressures and the COVID-19 pandemic response all point to virtual care as a viable and safe alternative to traditional models of chronic disease management. The lessons presented here provide more detailed guidance on the support that staff and patients require to ensure virtual care is a seamless and safe alternative or adjunct to traditional chronic disease management programs.

Analysis of community chronic disease health management mode under the background of big data

In recent years, the “Internet + medical” exploration and the country’s vigorously promoted hierarchical diagnosis and treatment system have provided an opportunity to improve the status quo of diabetes. Some scholars have proposed “one-to-one binding community nurses” (Wang Li et al., 2016) and personalized treatment based on big data (He Ting et al., 2016). New chronic disease management concepts such as an integrated chronic disease management model for the elderly based on mobile medical technology (Che Fengyuan et al., 2016). Although different names are used, the core point of view is that patients and community doctors complete the contract, the community doctors will take care of the patients, and the hospital doctors will take care of the patients. The patient’s blood glucose data can be shared with relatives and friends, community doctors, and hospital doctors in real time with the help of platform tools such as blood glucose meters, mobile apps, and cloud medical platforms. And community and hospital doctors’ feedback on patients can also be sent to patients and relatives and friends in real time, thereby realizing hierarchical diagnosis and treatment of diabetic patients when medical resources are scarce and unevenly distributed. This article refers to this model as the “family-style chronic disease management model”. The interaction between patients, relatives and friends, community doctors, and hospital doctors is shown in Figure 1.

Multilevel predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in rural South Africa: a panel study

ObjectiveIn 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. The objective of...