To protect the health of Diqing people throughout their life cycle, Ruijin Medical Aid Yunnan Team plans to build a plateau chronic disease management center
Diqing Prefecture is located in a high-altitude, cold and hypoxic area, and the average life expectancy in Diqing Prefecture is 14 years less than that in Shanghai. This is mainly related to the high incidence of plateau chronic diseases such as hypertension, hyperlipidemia, hyperuric acid, hyperglycemia, hyperhomocysteine, sleep apnea, polycythemia, pulmonary hypertension, plateau heart disease, cardiovascular and cerebrovascular accidents, which have not received enough attention and standardized management.
The Outline of the "Healthy China 2030" Plan proposes "co-construction and sharing, health for all", and clearly states that the core is to focus on people's health. Under the guidance of the "Healthy China" strategy, China's medical industry is undergoing a transformation from providing traditional medical insurance to providing intelligent and customized health services. To this end, the medical aid team of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine helped Diqing Prefecture People's Hospital to prepare for the establishment of a plateau chronic disease management center to protect the health of Diqing people throughout their life cycle.
The Plateau Chronic Disease Management Center of Diqing People's Hospital officially started operation on the third floor of the Health Management Center of Diqing People's Hospital on May 8, 2024. It mainly includes four departments:
National Standardized Metabolic Disease Management Center. MMC includes early screening, intervention, standardized treatment, re-examination, and regular follow-up. Diabetic patients can enjoy one-stop diagnosis and treatment services after arriving at the center. As long as the patient is included in the standardized management, even if he lives in other places, as long as he goes to a diagnosis and treatment institution with MMC, he can query the relevant diagnosis and treatment information, medication status, and follow-up time.
Sleep and breathing disorder management center. The center focuses on the following diseases: sleep disorders, chronic obstructive pulmonary disease, pulmonary hypertension, polycythemia vera, etc. Polysomnography can better assist in the diagnosis of sleep breathing disorders. According to different causes, non-invasive ventilation manual pressure titration and cognitive behavioral therapy for insomnia can also be performed.
Intelligent Hypertension Management Center. The center has joined the China Hypertension Alliance. After arriving at the center, patients can still enjoy one-stop diagnosis and treatment services; examination items include limb arterial blood pressure, vascular aging phenotype, 24-hour dynamic electrocardiogram, 24-hour dynamic blood pressure, cardiac color Doppler ultrasound and other related auxiliary examinations.
Stroke Prevention and Treatment Center. The center mainly focuses on diseases such as dizziness, headache, cerebral infarction, cerebral hemorrhage, epilepsy, etc. The examination items include.
The Plateau Chronic Disease Management Center of Diqing People's Hospital has introduced the health management concept of "prevention first, early checkpoints" from Ruijin Hospital to build a new full life cycle management model of prevention, screening, diagnosis, treatment, management and health.
Among them, "early prevention" means to improve health awareness through multi-channel popular science, and to popularize health knowledge and promote a healthy lifestyle through close integration of offline and online channels, so as to achieve the goal of "preventing diseases before they occur";
"Early screening" means regular screening linked to early diagnosis and early treatment. Regular screening is conducted for diseases with high incidence in Diqing Prefecture, cost-effective early treatment, and simple and easy screening methods. Rural medical vehicles are put into use to conduct regular screening of residents across the prefecture. Efforts are also made to improve service continuity to ensure that screened patients can quickly receive early diagnosis and treatment;
"Early diagnosis" refers to standardized outpatient clinics and remote outpatient clinics throughout the life cycle, linking the physical examination center and regular rounds screening with the chronic disease management center, and enrolling patients who need full-time management. After the doctor interviews and examines the patient, the information is entered into the system to form standardized medical history data, stratify risks, identify special and critical diseases, and give a diagnosis based on priority. For complex diseases, remote consultations can be conducted with Shanghai Ruijin Hospital in real time to discuss cases and provide patients with more accurate diagnosis and treatment plans;
"Early treatment" means combining centralized training with expert guidance to improve treatment levels. Through centralized training on diagnosis and treatment guidelines, expert consensus, the latest international and domestic progress, and typical cases and treatment plans of Shanghai Ruijin Hospital, single disease diagnosis and treatment standards are formed. Organize key doctors to participate in discussions on difficult cases at Shanghai Ruijin Hospital, as well as diversified training and guidance such as master-apprentice pairing, to promote the implementation of advanced diagnosis and treatment technologies in the Diqing Plateau Chronic Disease Management Center. When the condition is complicated or requires special treatment, the patient can be referred to Shanghai Ruijin Hospital for treatment;
"Early management" means caring service to improve patients' treatment compliance and overall satisfaction. The responsible doctor regularly reminds patients to follow the doctor's orders and return for follow-up visits on time to improve patient compliance and avoid worsening of the disease caused by delayed treatment. Through WeChat groups or telephone consultations, real-time analysis of disease trends, assessment of health status and treatment effects, and formulation of lifestyle management plans;
"Early rehabilitation" means formulating a personalized rehabilitation plan to consolidate the treatment results. Ask the rehabilitation doctors to formulate individualized rehabilitation plans according to the patient's condition. Inpatient treatment in the rehabilitation department and training of family members, after the patient is discharged from the hospital, the community will work together to supervise the patient's continuation of the rehabilitation plan. Through multi-channel popular science knowledge promotion, patients are encouraged to persevere.
The Chronic Disease/Altitude Sickness Management Center of Diqing People's Hospital will adopt a new full-life cycle management model of prevention, screening, diagnosis, treatment, management and rehabilitation to enable the people of Diqing to develop a healthy lifestyle and enjoy the medical resources of Shanghai Ruijin Hospital at their doorstep, thereby providing patients with maximum convenience in seeking medical treatment and reducing the incidence of chronic diseases in the plateau and the economic burden on society.
