01传统医疗模式下的慢病管理困境

　　01 Challenges in Chronic Disease Management under Traditional Medical Models

　　传统医疗机构：   以患者治疗为中心构建运营模式，其底层设计逻辑、资源分配机制、服务模式与慢病管理的核心需求存在根本性矛盾；临床医生：   考核体系过度依赖门诊量与手术量指标，缺乏参与连续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：   全周期管理链条割裂，院内诊疗与院外干预脱节，导致治疗依从性和疾病控制率不足，最终推高重大疾病发生风险与医保基金支出压力，形成"重治疗轻预防"的恶性循环。传统医疗体系与慢病管理存在系统性错位。

　　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 县域慢病管理业务巨大增长空间

　　02 County level chronic disease management business has huge growth potential

　　县医院能否获得短期收益，关键在于其医疗业务增长潜力，而慢病管理中蕴藏着显著收益空间。

　　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.

　　县域慢病管理中心专家委员会2024年对31家县医院的调研显示，县域各主要慢性病就诊率、复诊率、规范管理率及核心指标达标率均存在显著不足，通过优化服务可释放巨大增量空间。

　　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.

　　以全国县域平均人口38.8万测算，就诊率每提升10%，可增加年有效收入超过160万元；规范化管理率每提升10%，有效收入年增量超过450万元。若同步实施双提升策略，收益增长将呈现协同效应，即每同步提升就诊率10%和规范管理率10%，有效收入年增量将超过600万元。

　　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，规范管理率提升的单位效益显著高于就诊率提升的单位效益，因其通过优化干预方案、延长服务周期等机制，能同时实现提升服务价值和患者依从性。

　　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.

　　县医院若能以双提升为战略方向，不仅能破解短期收益困境，更能重构慢病管理的全周期服务链，为可持续发展奠定坚实基础。

　　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县医院如何抓住慢病管理的契机

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

　　慢病管理是县医院实现可持续发展的重要支柱。县域内最庞大的慢病患者群体具有长期持续性，其持续管理价值凸显。依托现有成熟的标准化慢病管理流程和循证医学指南，县医院具备构建主要慢性病规范化管理体系的基础框架。而要实现管理效能转化，关键在双重机制建设：

　　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. 临床专科深度协同：  将专科诊疗能力注入慢病管理全周期，既提升医疗质量，又通过专科医生参与增强患者信任度，形成业务粘性。

　　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. 精准干预能力建设：  针对患者依从性差、院外管理脱节等痛点，开发个性化干预方案。通过智能监测设备实施个性化干预提升患者依从性，建立院内院外相结合的管理机制强化服务连续性。

　　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.县医院需建立"短期收益与长期投入"的良性循环机制：初期：通过获取收益增量反哺管理工具迭代和专科能力建设激励；中期：持续优化管理流程、扩大服务范围，提升管理效率；长期：延伸服务链至全生命周期健康管理，形成可持续发展的战略支撑体系。

　　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慢病管理服务包提供标准化解决方案

　　04 Chronic Disease Management Service Package provides standardized solutions

　　为构建与县医院运营模式适配的慢病管理方法，中国疾控中心慢病中心联合县域慢病管理中心专家委员会及多学科权威专家，创新研发慢病管理服务包，针对县域慢病管理核心痛点给予标准化解决方案。1. 患者识别与分层体系：整合区域医疗数据平台，建立动态更新的慢病患者数据库，解决"患者在哪"的基础问题，为精准管理提供数据支撑。2. 筛查与促诊机制：通过筛查发现潜在患者，配套设计促诊流程，有效扩大服务覆盖。3. 认知干预体系：建立标准化健康评估流程，配套开发靶向教育模板，提升患者疾病认知水平。4. 个性化服务包：依据患者临床特征、医保类型及经济情况，根据各主要慢性病指南开发模块化管理方案，形成长期管理计划。5. 患者激励方案：根据医院实际运营情况，制定差异化患者优惠政策，激励患者签订长期管理协议。6. 长期跟进模式：建立线上线下相结合的随访机制，实施动态健康干预，有效维护长期管理关系。

　　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.

　　慢病管理服务包解决方案通过创新机制设计，构建了"短期收益-长期价值"的双轮驱动模式。在运营层面：通过筛查转化增量患者和标准化流程提升管理效率实现短期收益转化；在战略层面：则着力构建患者依从性培育体系、积累长期管理资产。既保障了服务开展的现金流基础，又通过提升管理质量创造了长期价值增长点，为县域慢病管理体系的持续优化提供了内生动力。

　　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.

　　05四大模型与慢病全流程管理

　　05 Four Models and the Whole Process Management of Chronic Diseases

　　基于县域慢病管理实践，慢病管理服务包创新构建四大智能模型，为县医院提供智能化全流程慢病管理支撑：1、筛查评估模型  针对高血压、糖尿病、慢阻肺、冠心病、脑卒中、慢性肾脏病等主要慢性病，研发适用多种场景的筛查评估工具。通过量化算法对患者并发症发生风险进行评估，生成包含干预预期获益值的个体化健康评估报告，并自动匹配靶向式疾病教育模板，为分级管理提供适宜工具。基于不同场景的筛查评估模型慢病管理服务包构建了场景化智能筛查体系，包含两种互补性评估模型：简易筛查模型采用轻量化问卷设计，集成身份证/医保卡信息读取功能，通过采集年龄、性别、BMI、血压、血糖、主要生活方式等核心参数，实时生成健康风险指数。适用于门诊预检分诊、社区义诊、线上筛查等快速筛查场景，单次评估用时＜3分钟，支持大样本人群初步风险分层。标准筛查模型在简易筛查模型基础上扩展采集生化检测指标、心电图结果等关键指标，构建多维度健康画像。依托国家指南开发慢病风险预测模型，可量化计算主要慢性病及其并发症发生风险概率等核心指标，自动生成包含分级管理建议的个体化报告。适用于门诊候诊区主动筛查场景。2、管理方案模型  深度融合临床指南与医保政策，构建决策树模型。根据患者病程、并发症等特征，智能适配个性化长期管理方案，同步核算管理成本，生成激励方案，确保方案的临床合规性与经济可行性。3、流程管理模型  基于县医院实际业务场景，设计线上线下协同的标准服务流程。开发智能随访系统，建立绩效考核体系，实现服务包实施的过程可追溯、质量可量化、效率可提升。4、效果评价模型  通过动态监测模型量化区域慢病管理改善效果，形成医保支付分析与医院运营评估的完整链条。

　　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快速生成个性化健康评估方案

　　06 Quickly generate personalized health assessment plans

　　慢病管理服务包构建了智能健康评估系统，整合电子病历、筛查数据及患者健康档案，建立个性化健康评估模型。可自动生成包含健康评分、疾病风险预测及管理建议的评估报告，并匹配个性化干预方案及对应靶向教育模块，让患者直观了解疾病情况及严重后果。支持门诊、住院、社区等多场景应用，实现精准健康管理。

　　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 设计适宜的慢病长期管理方案

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

　　慢病管理服务包以个体化健康评估为基础，构建了精准的分层管理模型。建立专科医师责任制，通过签约服务形成医患长期绑定机制，确保医疗服务的连续性与系统性。综合患者疾病特征、医保类型及支付能力，生成个性化年度管理方案。方案涵盖：就医规划：明确年度就诊频次、时序节点及就诊机构。干预实施：制定各次就诊的检查检验项目、用药方案及核心临床指标控制目标。服务支持：配置定制化附加服务及数字化健康管理工具。

　　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服务包设计遵循三级分层架构

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

　　基础包：构建慢病管理全周期基石，满足基本慢病管理需求标准包：参照各疾病临床指南的基本要求，构建规范化管理框架，增设并发症风险筛查及标准化药物治疗方案增值包：整合各疾病临床指南的基本要求，提供精准检测和个体化康复计划  慢病管理服务包的分层设计，既遵循医学规律，又兼顾卫生经济学效益，为慢病患者打造全维度、可进化的健康管理解决方案。

　　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创新县医院慢病管理获益模式

　　09 Innovative County Hospital Chronic Disease Management Benefit Model

　　慢病管理服务包模式构建了"医患价值共生"的收益体系，实现双方利益平衡。从供需两端重构价值链条，形成可持续的慢病管理生态系统。医院端价值重构路径

　　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

　　慢病管理服务包突破传统医疗单次获益的局限性，从"单次诊疗收费"转向"全病程服务获益"。虽然单次服务利润下降，但通过增加服务触点密度，延长患者管理周期，实现收益总量增长。

　　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.

　　通过患者激励机制，吸引潜在患者主动参与慢病管理，实现慢病人群的规模化精细管理。同时，将管理产生的增值收益按绩效考核反哺医疗团队，构建医患利益共同体，形成"控费即增收"的良性闭环。患者端价值提升路径   构建"医保报销+患者激励"的支付模式，通过报销与优惠政策合规降低患者单次医疗支出。基于规范年均就诊频次，延长服务周期，确保患者获得持续的慢病管理服务。

　　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.

　　通过附加服务和线上服务提升患者依从性。通过早期干预和持续管理，降低并发症发生率，有效减少因病情加重产生的额外医疗支出，实现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.

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