Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion
This study aims to elucidate the practical approaches and experiences of comorbidity management in Shanghai city, providing a reference for the Yangtze River Delta and other regions in China. Shanghai city has developed a comprehensive and closed-loop chronic disease health management system, which...
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| Main Authors: | , , , , , , , |
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| Format: | Article |
| Language: | zho |
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Editorial Office of Chinese Journal of Public Health
2024-10-01
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| Series: | Zhongguo gonggong weisheng |
| Subjects: | |
| Online Access: | https://www.zgggws.com/article/doi/10.11847/zgggws1144739 |
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| _version_ | 1832591026584289280 |
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| author | Mengyun SUI Sheng ZHANG Yuheng WANG Qinghua YAN Fei WU Chen FU Minna CHENG Yan SHI |
| author_facet | Mengyun SUI Sheng ZHANG Yuheng WANG Qinghua YAN Fei WU Chen FU Minna CHENG Yan SHI |
| author_sort | Mengyun SUI |
| collection | DOAJ |
| description | This study aims to elucidate the practical approaches and experiences of comorbidity management in Shanghai city, providing a reference for the Yangtze River Delta and other regions in China. Shanghai city has developed a comprehensive and closed-loop chronic disease health management system, which includes pre-diagnosis risk assessment and identification with tagged classification, intra-diagnosis standardized monitoring, data sharing integration, multidisciplinary collaboration, decision support, and post-diagnosis complication screening, intelligent follow-up, patient self-management, standardized health education, and re-evaluation. This system provides continuous medical care for patients with chronic comorbidities. Future potential directions and pathways for chronic comorbidity management include optimizing the social collaborative governance mechanism, further improving the network of community and social resource provision, refining the standards and mechanisms for referral of chronic disease patients, formulating shared decision-making and dynamic, continuous, and personalized care plans, and establishing a multidisciplinary collaboration mechanism for comorbidity patients in primary healthcare institutions. |
| format | Article |
| id | doaj-art-52b30d3236974743bb1df1f1ac4c0ed1 |
| institution | Kabale University |
| issn | 1001-0580 |
| language | zho |
| publishDate | 2024-10-01 |
| publisher | Editorial Office of Chinese Journal of Public Health |
| record_format | Article |
| series | Zhongguo gonggong weisheng |
| spelling | doaj-art-52b30d3236974743bb1df1f1ac4c0ed12025-01-23T05:11:55ZzhoEditorial Office of Chinese Journal of Public HealthZhongguo gonggong weisheng1001-05802024-10-0140101284128810.11847/zgggws11447391144739Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussionMengyun SUI0Sheng ZHANG1Yuheng WANG2Qinghua YAN3Fei WU4Chen FU5Minna CHENG6Yan SHI7Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Health Commission, Shanghai 200120Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaShanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, ChinaThis study aims to elucidate the practical approaches and experiences of comorbidity management in Shanghai city, providing a reference for the Yangtze River Delta and other regions in China. Shanghai city has developed a comprehensive and closed-loop chronic disease health management system, which includes pre-diagnosis risk assessment and identification with tagged classification, intra-diagnosis standardized monitoring, data sharing integration, multidisciplinary collaboration, decision support, and post-diagnosis complication screening, intelligent follow-up, patient self-management, standardized health education, and re-evaluation. This system provides continuous medical care for patients with chronic comorbidities. Future potential directions and pathways for chronic comorbidity management include optimizing the social collaborative governance mechanism, further improving the network of community and social resource provision, refining the standards and mechanisms for referral of chronic disease patients, formulating shared decision-making and dynamic, continuous, and personalized care plans, and establishing a multidisciplinary collaboration mechanism for comorbidity patients in primary healthcare institutions.https://www.zgggws.com/article/doi/10.11847/zgggws1144739community health servicesco-morbidity managementsupport centerpractical experience |
| spellingShingle | Mengyun SUI Sheng ZHANG Yuheng WANG Qinghua YAN Fei WU Chen FU Minna CHENG Yan SHI Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion Zhongguo gonggong weisheng community health services co-morbidity management support center practical experience |
| title | Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion |
| title_full | Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion |
| title_fullStr | Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion |
| title_full_unstemmed | Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion |
| title_short | Practice of comorbidity management based on community chronic disease health management support centers: an introduction and discussion |
| title_sort | practice of comorbidity management based on community chronic disease health management support centers an introduction and discussion |
| topic | community health services co-morbidity management support center practical experience |
| url | https://www.zgggws.com/article/doi/10.11847/zgggws1144739 |
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