01傳統醫療模式下的慢病管理困境

　　01 Challenges in Chronic Disease Management under Traditional Medical Models

　　傳統醫療機構：   以患者治療為中心構建運營模式，其底層設計邏輯、資源分配機制、服務模式與慢病管理的核心需求存在根本性矛盾；臨床醫生：   考核體系過度依賴門診量與手術量指標，缺乏參與連續性健康管理的制度性通道；

　　Traditional medical institutions: constructing an operational model centered on patient treatment, which fundamentally contradicts the core needs of chronic disease management in terms of underlying design logic, resource allocation mechanisms, service models, and chronic disease management; Clinical doctors: The assessment system overly relies on outpatient and surgical volume indicators, lacking institutional channels for participating in continuous health management;

　　患者：   全周期管理鏈條割裂，院內診療與院外干預脫節，導致治療依從性和疾病控制率不足，最終推高重大疾病發生風險與醫保基金支出壓力，形成"重治療輕預防"的惡性循環。傳統醫療體系與慢病管理存在系統性錯位。

　　Patient: The whole cycle management chain is fragmented, and there is a disconnect between in-hospital diagnosis and treatment and out of hospital intervention, resulting in insufficient treatment compliance and disease control rate, ultimately pushing up the risk of major diseases and the pressure of medical insurance fund expenditure, forming a vicious cycle of "emphasizing treatment over prevention". There is a systematic mismatch between the traditional medical system and chronic disease management.

　　02 縣域慢病管理業務巨大增長空間

　　02 County level chronic disease management business has huge growth potential

　　縣醫院能否獲得短期收益，關鍵在于其醫療業務增長潛力，而慢病管理中蘊藏著顯著收益空間。

　　The key to whether county hospitals can obtain short-term benefits lies in their potential for medical business growth, and there is significant profit potential in chronic disease management.

　　縣域慢病管理中心專家委員會2024年對31家縣醫院的調研顯示，縣域各主要慢性病就診率、復診率、規范管理率及核心指標達標率均存在顯著不足，通過優化服務可釋放巨大增量空間。

　　The expert committee of the County Chronic Disease Management Center conducted a survey of 31 county hospitals in 2024, which showed that there were significant deficiencies in the treatment rate, follow-up rate, standardized management rate, and core indicator compliance rate of major chronic diseases in the county. By optimizing services, huge incremental space can be released.

　　以全國縣域平均人口38.8萬測算，就診率每提升10%，可增加年有效收入超過160萬元；規范化管理率每提升10%，有效收入年增量超過450萬元。若同步實施雙提升策略，收益增長將呈現協同效應，即每同步提升就診率10%和規范管理率10%，有效收入年增量將超過600萬元。

　　Based on the average population of 388000 counties in China, an increase of 10% in medical treatment rate can increase annual effective income by over 1.6 million yuan; For every 10% increase in standardized management rate, the annual increase in effective income exceeds 4.5 million yuan. If the dual promotion strategy is implemented simultaneously, the revenue growth will show a synergistic effect, that is, for every 10% increase in the medical treatment rate and standardized management rate, the annual increase in effective income will exceed 6 million yuan.

　　值得注意的是，規范管理率提升的單位效益顯著高于就診率提升的單位效益，因其通過優化干預方案、延長服務周期等機制，能同時實現提升服務價值和患者依從性。

　　It is worth noting that the unit benefits of improving standardized management rates are significantly higher than those of improving medical treatment rates, as they can simultaneously enhance service value and patient compliance through mechanisms such as optimizing intervention plans and extending service cycles.

　　縣醫院若能以雙提升為戰略方向，不僅能破解短期收益困境，更能重構慢病管理的全周期服務鏈，為可持續發展奠定堅實基礎。

　　If the county hospital can take dual upgrading as its strategic direction, it can not only solve the short-term profit dilemma, but also reconstruct the full cycle service chain of chronic disease management, laying a solid foundation for sustainable development.

　　03縣醫院如何抓住慢病管理的契機

　　How to seize the opportunity of chronic disease management in County Hospital 03

　　慢病管理是縣醫院實現可持續發展的重要支柱。縣域內最龐大的慢病患者群體具有長期持續性，其持續管理價值凸顯。依托現有成熟的標準化慢病管理流程和循證醫學指南，縣醫院具備構建主要慢性病規范化管理體系的基礎框架。而要實現管理效能轉化，關鍵在雙重機制建設：

　　Chronic disease management is an important pillar for county hospitals to achieve sustainable development. The largest group of chronic disease patients in the county has long-term sustainability, and its value in sustainable management is highlighted. Based on the existing mature standardized chronic disease management process and evidence-based medicine guidelines, the county hospital has the basic framework to build a standardized management system for major chronic diseases. To achieve the transformation of management efficiency, the key lies in the construction of a dual mechanism:

　　1. 臨床專科深度協同：  將專科診療能力注入慢病管理全周期，既提升醫療質量，又通過專科醫生參與增強患者信任度，形成業務粘性。

　　1. Deep collaboration between clinical specialties: Injecting specialized diagnosis and treatment capabilities into the entire cycle of chronic disease management, not only improving medical quality, but also enhancing patient trust through the participation of specialized doctors, forming business stickiness.

　　2. 精準干預能力建設：  針對患者依從性差、院外管理脫節等痛點，開發個性化干預方案。通過智能監測設備實施個性化干預提升患者依從性，建立院內院外相結合的管理機制強化服務連續性。

　　2. Precision intervention capacity building: Develop personalized intervention plans to address pain points such as poor patient compliance and disconnection from out of hospital management. Implementing personalized interventions through intelligent monitoring devices to enhance patient compliance, establishing a management mechanism that combines internal and external factors, and strengthening service continuity.

　　3.縣醫院需建立"短期收益與長期投入"的良性循環機制：初期：通過獲取收益增量反哺管理工具迭代和專科能力建設激勵；中期：持續優化管理流程、擴大服務范圍，提升管理效率；長期：延伸服務鏈至全生命周期健康管理，形成可持續發展的戰略支撐體系。

　　3. County hospitals need to establish a virtuous cycle mechanism of "short-term benefits and long-term investment": in the initial stage, by obtaining incremental benefits to feed back management tools iteration and specialized capacity building incentives; Mid term: Continuously optimize management processes, expand service scope, and improve management efficiency; Long term: Extend the service chain to full lifecycle health management, forming a strategic support system for sustainable development.

　　04慢病管理服務包提供標準化解決方案

　　04 Chronic Disease Management Service Package provides standardized solutions

　　為構建與縣醫院運營模式適配的慢病管理方法，中國疾控中心慢病中心聯合縣域慢病管理中心專家委員會及多學科權威專家，創新研發慢病管理服務包，針對縣域慢病管理核心痛點給予標準化解決方案。1. 患者識別與分層體系：整合區域醫療數據平臺，建立動態更新的慢病患者數據庫，解決"患者在哪"的基礎問題，為精準管理提供數據支撐。2. 篩查與促診機制：通過篩查發現潛在患者，配套設計促診流程，有效擴大服務覆蓋。3. 認知干預體系：建立標準化健康評估流程，配套開發靶向教育模板，提升患者疾病認知水平。4. 個性化服務包：依據患者臨床特征、醫保類型及經濟情況，根據各主要慢性病指南開發模塊化管理方案，形成長期管理計劃。5. 患者激勵方案：根據醫院實際運營情況，制定差異化患者優惠政策，激勵患者簽訂長期管理協議。6. 長期跟進模式：建立線上線下相結合的隨訪機制，實施動態健康干預，有效維護長期管理關系。

　　To build a chronic disease management method that is compatible with the operation mode of county hospitals, the Chronic Disease Center of the Chinese Center for Disease Control and Prevention, together with the Expert Committee of County Chronic Disease Management Centers and multidisciplinary authoritative experts, has innovatively developed a chronic disease management service package, providing standard solutions for the core pain points of county-level chronic disease management. 1. Patient identification and stratification system: Integrate regional medical data platforms, establish a dynamically updated chronic disease patient database, solve the basic problem of "where the patient is", and provide data support for precise management. 2. Screening and promotion mechanism: Potential patients are identified through screening, and a matching promotion process is designed to effectively expand service coverage. 3. Cognitive intervention system: Establish a standardized health assessment process, develop targeted education templates, and enhance patients' disease awareness. 4. Personalized service package: Based on the patient's clinical characteristics, medical insurance type, and economic situation, develop modular management plans according to the guidelines for major chronic diseases, and form long-term management plans. 5. Patient incentive plan: Based on the actual operation of the hospital, develop differentiated patient preferential policies and encourage patients to sign long-term management agreements. 6. Long term follow-up mode: Establish a combined online and offline follow-up mechanism, implement dynamic health interventions, and effectively maintain long-term management relationships.

　　慢病管理服務包解決方案通過創新機制設計，構建了"短期收益-長期價值"的雙輪驅動模式。在運營層面：通過篩查轉化增量患者和標準化流程提升管理效率實現短期收益轉化；在戰略層面：則著力構建患者依從性培育體系、積累長期管理資產。既保障了服務開展的現金流基礎，又通過提升管理質量創造了長期價值增長點，為縣域慢病管理體系的持續優化提供了內生動力。

　　The chronic disease management service package solution has been designed through innovative mechanisms, constructing a dual wheel drive model of "short-term benefits - long-term value". At the operational level, short-term revenue conversion is achieved by screening and converting incremental patients and standardizing processes to improve management efficiency; At the strategic level, efforts will be made to build a patient compliance cultivation system and accumulate long-term management assets. It not only ensures the cash flow foundation for service development, but also creates long-term value growth points by improving management quality, providing endogenous motivation for the continuous optimization of the county-level chronic disease management system.

　　05四大模型與慢病全流程管理

　　05 Four Models and the Whole Process Management of Chronic Diseases

　　基于縣域慢病管理實踐，慢病管理服務包創新構建四大智能模型，為縣醫院提供智能化全流程慢病管理支撐：1、篩查評估模型  針對高血壓、糖尿病、慢阻肺、冠心病、腦卒中、慢性腎臟病等主要慢性病，研發適用多種場景的篩查評估工具。通過量化算法對患者并發癥發生風險進行評估，生成包含干預預期獲益值的個體化健康評估報告，并自動匹配靶向式疾病教育模板，為分級管理提供適宜工具。基于不同場景的篩查評估模型慢病管理服務包構建了場景化智能篩查體系，包含兩種互補性評估模型：簡易篩查模型采用輕量化問卷設計，集成身份證/醫保卡信息讀取功能，通過采集年齡、性別、BMI、血壓、血糖、主要生活方式等核心參數，實時生成健康風險指數。適用于門診預檢分診、社區義診、線上篩查等快速篩查場景，單次評估用時＜3分鐘，支持大樣本人群初步風險分層。標準篩查模型在簡易篩查模型基礎上擴展采集生化檢測指標、心電圖結果等關鍵指標，構建多維度健康畫像。依托國家指南開發慢病風險預測模型，可量化計算主要慢性病及其并發癥發生風險概率等核心指標，自動生成包含分級管理建議的個體化報告。適用于門診候診區主動篩查場景。2、管理方案模型  深度融合臨床指南與醫保政策，構建決策樹模型。根據患者病程、并發癥等特征，智能適配個性化長期管理方案，同步核算管理成本，生成激勵方案，確保方案的臨床合規性與經濟可行性。3、流程管理模型  基于縣醫院實際業務場景，設計線上線下協同的標準服務流程。開發智能隨訪系統，建立績效考核體系，實現服務包實施的過程可追溯、質量可量化、效率可提升。4、效果評價模型  通過動態監測模型量化區域慢病管理改善效果，形成醫保支付分析與醫院運營評估的完整鏈條。

　　Based on the practice of chronic disease management in the county, the chronic disease management service package innovatively builds four intelligent models to provide the county hospital with intelligent full process chronic disease management support: 1. The screening and evaluation model develops screening and evaluation tools suitable for multiple scenarios for major chronic diseases such as hypertension, diabetes, chronic obstructive pulmonary disease, coronary heart disease, stroke, chronic kidney disease, etc. Evaluate the risk of complications in patients through quantitative algorithms, generate personalized health assessment reports containing expected intervention benefits, and automatically match targeted disease education templates to provide appropriate tools for hierarchical management. A scenario based intelligent screening system for chronic disease management service package has been constructed based on screening and evaluation models in different scenarios, including two complementary evaluation models: the simple screening model adopts a lightweight questionnaire design, integrates ID/medical insurance card information reading function, and collects information by age, gender BMI、 Real time generation of health risk index based on core parameters such as blood pressure, blood sugar, and major lifestyle habits. Suitable for rapid screening scenarios such as outpatient pre screening triage, community free clinics, and online screening, with a single assessment time of less than 3 minutes, supporting preliminary risk stratification of large sample populations. The standard screening model extends the collection of key indicators such as biochemical testing indicators and electrocardiogram results based on the simple screening model, and constructs a multidimensional health profile. Developing a chronic disease risk prediction model based on national guidelines, which can quantitatively calculate core indicators such as the probability of occurrence of major chronic diseases and their complications, and automatically generate personalized reports containing graded management recommendations. Suitable for active screening scenarios in outpatient waiting areas. 2. The management plan model deeply integrates clinical guidelines and medical insurance policies, and constructs a decision tree model. Based on the patient's course of illness, complications, and other characteristics, intelligent adaptation of personalized long-term management plans, synchronous accounting of management costs, generation of incentive plans, and ensuring the clinical compliance and economic feasibility of the plans. 3. The process management model is based on the actual business scenarios of county hospitals, and designs standard service processes for online and offline collaboration. Develop an intelligent follow-up system, establish a performance evaluation system, and achieve traceable process, quantifiable quality, and improved efficiency in the implementation of service packages. 4. The effectiveness evaluation model quantifies the improvement effect of regional chronic disease management through dynamic monitoring models, forming a complete chain of medical insurance payment analysis and hospital operation evaluation.

　　06快速生成個性化健康評估方案

　　06 Quickly generate personalized health assessment plans

　　慢病管理服務包構建了智能健康評估系統，整合電子病歷、篩查數據及患者健康檔案，建立個性化健康評估模型。可自動生成包含健康評分、疾病風險預測及管理建議的評估報告，并匹配個性化干預方案及對應靶向教育模塊，讓患者直觀了解疾病情況及嚴重后果。支持門診、住院、社區等多場景應用，實現精準健康管理。

　　The chronic disease management service package has built an intelligent health assessment system, integrating electronic medical records, screening data, and patient health records to establish a personalized health assessment model. It can automatically generate evaluation reports containing health scores, disease risk predictions, and management recommendations, and match personalized intervention plans and corresponding targeted education modules, allowing patients to intuitively understand the disease situation and serious consequences. Support multi scenario applications such as outpatient, inpatient, and community settings to achieve precise health management.

　　07 設計適宜的慢病長期管理方案

　　07 Design a suitable long-term management plan for chronic diseases

　　慢病管理服務包以個體化健康評估為基礎，構建了精準的分層管理模型。建立專科醫師責任制，通過簽約服務形成醫患長期綁定機制，確保醫療服務的連續性與系統性。綜合患者疾病特征、醫保類型及支付能力，生成個性化年度管理方案。方案涵蓋：就醫規劃：明確年度就診頻次、時序節點及就診機構。干預實施：制定各次就診的檢查檢驗項目、用藥方案及核心臨床指標控制目標。服務支持：配置定制化附加服務及數字化健康管理工具。

　　The chronic disease management service package is based on individualized health assessment and constructs a precise hierarchical management model. Establish a specialized physician responsibility system, establish a long-term doctor-patient binding mechanism through contracted services, and ensure the continuity and systematicity of medical services. Generate personalized annual management plans based on the patient's disease characteristics, medical insurance type, and payment ability. The plan covers: medical planning: clarifying the annual frequency of visits, timing nodes, and medical institutions. Intervention implementation: Develop examination and testing items, medication plans, and core clinical indicator control objectives for each visit. Service support: Configure customized additional services and digital health management tools.

　　08服務包設計遵循三級分層架構

　　The design of the 08 service package follows a three-tier hierarchical architecture

　　基礎包：構建慢病管理全周期基石，滿足基本慢病管理需求標準包：參照各疾病臨床指南的基本要求，構建規范化管理框架，增設并發癥風險篩查及標準化藥物治療方案增值包：整合各疾病臨床指南的基本要求，提供精準檢測和個體化康復計劃  慢病管理服務包的分層設計，既遵循醫學規律，又兼顧衛生經濟學效益，為慢病患者打造全維度、可進化的健康管理解決方案。

　　Basic package: Building the cornerstone of chronic disease management throughout the entire cycle, meeting basic chronic disease management needs. Standard package: Referring to the basic requirements of clinical guidelines for various diseases, constructing a standardized management framework, adding complication risk screening and standardized drug treatment plans. Value added package: Integrating the basic requirements of clinical guidelines for various diseases, providing precise detection and personalized rehabilitation plans. The layered design of chronic disease management service package not only follows medical laws but also takes into account health economics benefits, creating a comprehensive and evolving health management solution for chronic disease patients.

　　09創新縣醫院慢病管理獲益模式

　　09 Innovative County Hospital Chronic Disease Management Benefit Model

　　慢病管理服務包模式構建了"醫患價值共生"的收益體系，實現雙方利益平衡。從供需兩端重構價值鏈條，形成可持續的慢病管理生態系統。醫院端價值重構路徑

　　The chronic disease management service package model has established a profit system of "symbiotic value between doctors and patients", achieving a balance of interests between both parties. Reconstruct the value chain from both supply and demand ends to form a sustainable chronic disease management ecosystem. The path of value reconstruction on the hospital side

　　慢病管理服務包突破傳統醫療單次獲益的局限性，從"單次診療收費"轉向"全病程服務獲益"。雖然單次服務利潤下降，但通過增加服務觸點密度，延長患者管理周期，實現收益總量增長。

　　The chronic disease management service package breaks through the limitations of traditional medical single benefit and shifts from "single diagnosis and treatment fee" to "full course service benefit". Although the profit of a single service has decreased, the total revenue has increased by increasing the density of service touchpoints and extending the patient management cycle.

　　通過患者激勵機制，吸引潛在患者主動參與慢病管理，實現慢病人群的規模化精細管理。同時，將管理產生的增值收益按績效考核反哺醫療團隊，構建醫患利益共同體，形成"控費即增收"的良性閉環。患者端價值提升路徑   構建"醫保報銷+患者激勵"的支付模式，通過報銷與優惠政策合規降低患者單次醫療支出。基于規范年均就診頻次，延長服務周期，確保患者獲得持續的慢病管理服務。

　　Through patient incentive mechanisms, potential patients are attracted to actively participate in chronic disease management, achieving large-scale and refined management of chronic disease populations. At the same time, the value-added benefits generated by management will be fed back to the medical team through performance evaluation, building a community of shared interests between doctors and patients, and forming a virtuous closed loop of "cost control equals income increase". Constructing a payment model of "medical insurance reimbursement+patient incentives" to enhance the value of the patient side, reducing single medical expenses for patients through compliance with reimbursement and preferential policies. Based on the standardized annual frequency of visits, the service period is extended to ensure that patients receive continuous chronic disease management services.

　　通過附加服務和線上服務提升患者依從性。通過早期干預和持續管理，降低并發癥發生率，有效減少因病情加重產生的額外醫療支出，實現患者全生命周期健康管理。

　　Improve patient compliance through additional services and online services. By early intervention and continuous management, the incidence of complications can be reduced, the additional medical expenses caused by worsening of the condition can be effectively reduced, and the whole life cycle health management of patients can be achieved.

　　本文由 慢病隨訪包  友情奉獻.更多有關的知識請點擊  http://www.yywed.cn/   真誠的態度.為您提供為全面的服務.更多有關的知識我們將會陸續向大家奉獻.敬請期待.

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