Work plan for prevention and treatment of chronic diseases

Work plan for prevention and treatment of chronic diseases 1 I. Work objectives

1. Establish a basic information system for chronic diseases, make use of the existing network to directly report newly diagnosed cases of coronary heart disease, stroke, diabetes and malignant tumor, and formulate a network direct reporting system for chronic diseases. The leadership is responsible for this work, and the responsibility is implemented to people. The CDC conducts inspection and supervision on chronic disease reports every quarter, and writes a briefing.

2, the use of residents' health records and organize residents to carry out health examination, early detection of hypertension and diabetes, improve the early diagnosis rate and early treatment rate of hypertension and diabetes.

3. Strengthen the follow-up management of patients with hypertension and diabetes in the community, improve the standardized management rate and control rate of hypertension and diabetes, improve the self-management and knowledge and skills of patients with hypertension and diabetes, and reduce or delay the occurrence of complications of hypertension and diabetes.

4. On the basis of community health service centers (stations), starting with group prevention and control and individual prevention and control, explore the mode of establishing district CDC management and evaluation, general hospital assisting diagnosis, individualized treatment and providing technical support, and community health service centers (stations) following up to manage hypertension and diabetes.

5, strengthen health education and health promotion, regularly carry out lectures and publicity on hypertension and diabetes, popularize community residents' knowledge of prevention and treatment of hypertension and diabetes, control various risk factors, and improve people's health awareness.

6. Establish a standardized computer file management system for hypertension and diabetes.

Second, the filing work objectives

1. Establish health records of community residents, and the baseline survey rate of community service population is over 40%;

2. Establish health records of patients with hypertension and diabetes, with follow-up records, treatment records and health education records.

Third, the goal of hypertension work

1, find and register at least 100 hypertensive patients;

2. Standardize the management of at least 20 patients, and the blood pressure control rate is ≥ 60%;

3. Discover and register at least 20 high-risk groups;

4.50% of the high-risk population measured their blood pressure at least 1 time every year;

5. The intervention of high-risk groups is recorded and the effect is evaluated;

6.60% residents over 35 years old have their blood pressure measured at least 1 time within 3 years;

7. The awareness rate of hypertension prevention knowledge among residents is 60%.

Four, diabetes work objectives

1, at least 30 diabetic patients were found and registered;

2. Standardize the management of at least 15 diabetic patients, and the blood sugar control rate reaches 60%;

3. Find and register the high-risk population 10, and the ratio of blood sugar test 1 time at least reaches 40% every year;

4. The awareness rate of prevention and control knowledge among high-risk groups is 60%;

5, the health education of high-risk groups and the general population is recorded and evaluated.

Verb (abbreviation for verb) implementation plan

Establish a network direct reporting system and working system for chronic diseases; To carry out the prevention and control of the general population, hypertension and diabetes in the community, and establish a comprehensive prevention and control mechanism for hypertension and diabetes in the community.

(a) the use of the existing network direct reporting system, this year's new cases of coronary heart disease, diabetes, stroke, malignant tumor network direct reporting. Establish a chronic disease reporting system, and the responsibility lies with people.

(2) management of hypertension and diabetes

1, detecting hypertension and diabetes.

Patients with hypertension and diabetes were found by establishing health records of community residents, physical examination, diagnosis and treatment in community health service centers, free blood pressure measurement and blood sugar measurement in communities, active blood pressure measurement and first blood pressure measurement.

2. Registration of patients with hypertension and diabetes

Establish management cards for patients with hypertension and diabetes who have been detected and those who have been reported by Chengdu Chronic Disease Reporting Network in the community, and input all information into relevant databases for computerized management.

3. Follow-up management and referral of patients with hypertension

Collect the detailed medical history of the detected hypertension patients, carry out necessary physical examination and laboratory examination, conduct clinical evaluation according to the requirements of the Basic Norms for Hypertension Prevention and Treatment, implement graded management and follow-up, and fill out the community hypertension patient management card. Hypertensive patients receive drug therapy and non-drug therapy. When the patient has the situation stipulated in the Basic Operation Standard for Hypertension Prevention and Control, he will be referred to the superior general hospital in time, and then transferred back to the community health service center (station) for further treatment and follow-up after his condition is stable. Help patients make self-management plans and provide technical support for self-management of patients with hypertension.

4. Follow-up management and referral of diabetic patients.

According to the patient's clinical situation and comprehensive treatment plan, the detected diabetic patients are judged as the management category that needs follow-up management, and the Community Diabetes Patient Management Card is filled in. Medication and non-medication for diabetic patients. When the patient has a condition that meets the referral situation, he will be referred to the superior general hospital in time, and then transferred back to the community health service center (station) for further treatment and follow-up after the condition is stable. Help diabetics make self-management plans and provide self-management support for diabetics.

(3) Health guidance and intervention for high-risk groups of hypertension and diabetes.

1, definition and detection of high-risk population of hypertension and diabetes.

According to the definition standards of high-risk groups of hypertension and diabetes, the high-risk groups of hypertension and diabetes were found through daily diagnosis and treatment, physical examination, establishment of health records and active screening.

2. Health guidance and intervention for high-risk groups of hypertension and diabetes.

Take the method of combining group and individual health guidance for high-risk groups, carry out health education to change unhealthy lifestyles, improve high-risk groups' understanding of hypertension, diabetes and risk factors through health education, give guidance on healthy lifestyles, and measure blood pressure and blood sugar regularly.

(d) Promoting the health of the general population in the community.

According to the health needs of the community population, widely publicize the knowledge of prevention and treatment of hypertension and diabetes in the community, advocate a healthy lifestyle, encourage the community population to change unhealthy lifestyles, reduce risk factors, and prevent and reduce the occurrence of hypertension and diabetes.

1. Establish a publicity window for prevention and treatment of hypertension and diabetes in the community, change the content 1 time every February, make a leaflet on prevention and treatment of hypertension and diabetes, and distribute it to the community people through neighborhood committees and medical stations.

2. Hold a lecture on hypertension and diabetes, a lecture on healthy lifestyle and a free clinic in the community once a month.

3, the use of community residents' activity rooms and other places where residents are concentrated as propaganda positions for the prevention and treatment of hypertension and diabetes, and put all kinds of publicity materials.

4. Carry out free blood pressure and blood sugar measurement activities in the community.

Cultivation of intransitive verbs

In order to improve the management quality of hypertension and diabetes, doctors in community health service centers (stations) were trained in accordance with Basic Operating Rules for Hypertension Prevention, Guidelines for Hypertension Prevention in China and Guidelines for Diabetes Prevention in China.

Seven. evaluate

1, process evaluation

Dynamic management of hypertension and diabetes, follow-up management of hypertension and diabetes, implementation of two-way referral, first blood pressure measurement of 35-year-old patients, patient satisfaction, etc.

2. Effect evaluation

Awareness rate of knowledge about prevention and treatment of hypertension and diabetes, change rate of risk behaviors related to hypertension and diabetes, blood pressure and blood sugar control rate of hypertension and diabetes, and standardized drug treatment rate.

VIII. Supervision and Assessment

(a), organized by the District Health Bureau supervision and evaluation, evaluation opinions timely feedback to the inspected units, in order to improve the work in a timely manner.

(two), community health service center (station) to develop internal working system, workflow and quality control rules and regulations, strengthen self-examination.

(3), assessment indicators

1, the filing rate and qualified rate of patients with hypertension and diabetes in the community;

2. The number and standardized management rate of patients with hypertension and diabetes in the community;

3, community medical personnel training and training qualified rate;

4. Awareness rate of hypertension and diabetes prevention knowledge in community population;

5. Lifestyle change rate of patients with hypertension and diabetes;

6. Control rate of hypertension and diabetes;

7. Formulation and implementation of working system;

8. Recording and archiving of various activities.

Task objective of chronic disease prevention and control work plan 2 (1)

1, implement the first diagnosis of blood pressure measurement system for community residents over 35 years old; Measure blood pressure and blood sugar at least once a year.

2. For newly discovered patients with hypertension and diabetes, standardized and complete files must be established. The filing rate and standardized management rate are over 95%, and the effective follow-up rate is 85%.

The registration rates of hypertension and diabetes among registered residents over 3.35 years old should reach 85% and 2% respectively.

4. The reported data of hypertension, diabetes, stroke and tumor are accurate, complete and timely.

(2) Specific measures

1, there is a special person responsible for the prevention and treatment of chronic diseases in the community.

2, found suspicious TB patients immediately transferred to TB prevention and control institutions for further examination, are not allowed to prescribe anti-tuberculosis drugs.

3, the implementation of full supervision and treatment of infectious pulmonary tuberculosis patients. The standardized drug use rate should reach more than 98%. And timely guide patients to do the necessary examination and sputum re-examination on time, and handle or report the side effects in time.

4. For the first time, community residents over 20 years old take part in the blood pressure test of registered population, and residents over 35 years old take part in the blood pressure and blood sugar test at least once a year, and do a good job in regular physical examination of residents (once a year or once every two years).

5. Grasp the number of residents with hypertension and diabetes in the area, have standardized and complete medical records and registration (hypertension registration rate is 5%, diabetes is 2%), and the standardized management and follow-up rate is over 95%. Quarterly, semi-annual and year-end evaluation should meet the requirements of blood pressure control compliance rate, blood sugar control good rate and case effect evaluation.

6, master the basic situation of the elderly population over 60 years old (resident population) and have a roster, health records and other information is complete, to carry out regular physical examination of the elderly, with work records and information.

7, according to the requirements of the key population supervision visits, and recorded.

8, in accordance with the requirements of chronic disease prevention and control, timely, accurate, complete and standardized statistics of the original data related to chronic disease prevention and control work into statements, and report on time.

9, according to the needs of the prevention and treatment of various chronic diseases, and actively carry out the corresponding prevention and treatment of chronic diseases, health education and health promotion.

Work Plan for the Prevention and Treatment of Chronic Diseases 3 With the continuous development of globalization, urbanization and aging, the disease burden caused by chronic diseases has increased year by year, surpassing infectious diseases. Chronic diseases such as cardiovascular and cerebrovascular diseases, tumors, diabetes and respiratory diseases have become the main public health problems threatening China residents. In order to effectively strengthen and do a good job in the prevention and treatment of chronic diseases in our city, according to the requirements of the National Basic Public Health Service Standard (20xx Edition) and the National Standard for the Prevention and Treatment of Chronic Diseases, the work plan for the prevention and treatment of chronic diseases this year is formulated.

The first is to implement basic public health service standards.

1. Establish a basic information management system for chronic diseases. All districts and counties should conscientiously do a good job in the monthly report of basic public health chronic disease projects, review the reports submitted by the grassroots, and report the development of chronic disease work in all districts and counties 1 month to the Municipal Center for Disease Control and Prevention before the 2nd of each month.

2. Standardize chronic disease screening. All districts and counties should urge community health service centers (stations) and township health centers under their jurisdiction to find patients with hypertension and diabetes as early as possible by establishing residents' health records and organizing residents' health checkups, so as to improve the early diagnosis rate and early treatment rate of hypertension and diabetes.

3. Actively carry out various intervention services. Strengthen the health management of high-risk groups of chronic diseases and regularly monitor the level of risk factors. Blood pressure and fasting blood glucose of high-risk population are every six months 1 time, and every year 1 time. At the same time, reasonable diet, proper exercise, tobacco control and alcohol restriction are given, and the intensity of intervention is constantly adjusted, and drug prevention is carried out when necessary. Strengthen the community and township follow-up management of patients with hypertension and diabetes, and regularly follow up behavior intervention and treatment guidance at least four times a year to improve the standardized management rate and control rate. The standardized management rate of hypertension and diabetes is not less than 80% respectively, and the control rate of blood pressure and blood sugar is not less than 30% and 25% respectively, so as to improve the self-management knowledge and skills of patients with hypertension and diabetes. Complete the indicators of hypertension and diabetes patients issued by the Health Bureau in 20xx.

4. Vigorously promote health education and health promotion actions. Districts and counties should strengthen health education and health promotion in the prevention and treatment of chronic diseases, take various forms, and use various health theme days related to the prevention and treatment of chronic diseases to carry out related theme activities. Conduct lectures and publicity on hypertension and diabetes regularly, popularize the knowledge of prevention and treatment of hypertension and diabetes among community residents, control various risk factors, and improve people's health awareness.

5. Do a solid job in evaluation and diagnosis. Communities and towns should complete the annual report on community health and wellness. District CDC should complete the community diagnosis of chronic diseases and report to the municipal CDC.

Two, actively create a demonstration zone for comprehensive prevention and control of chronic non-communicable diseases.

According to the spirit of the Guiding Plan for Comprehensive Prevention and Control of Chronic Non-communicable Diseases, in order to promote the construction of chronic disease prevention and control demonstration zones in our city and form a demonstration-driven effect, this year, the establishment of chronic disease prevention and control demonstration zones will be carried out in the whole region, and other districts and counties should also make preparations before the establishment. The Municipal Center for Disease Control and Prevention will regularly supervise and inspect the demonstration creation according to the requirements of the guidance plan.

Third, we will comprehensively launch the national healthy lifestyle campaign.

In order to further promote the healthy lifestyle of the whole people, according to the requirements of Tongchuan National Healthy Lifestyle Action Plan, all districts and counties should actively carry out the creation of "demonstration units", "demonstration communities" and "demonstration canteens/restaurants" in light of local conditions, accumulate experience, continuously expand the types and coverage of creating demonstrations, and gradually promote the action of healthy lifestyle of the whole people. At the same time, do a good job in collecting and reporting information on healthy lifestyles of the whole people.

Four, strengthen the business training of chronic disease prevention and control personnel.

In order to strengthen the construction of chronic disease prevention and control team in our city, a regular step-by-step guidance and training system is established in accordance with the requirements of the "Regulations on the Prevention and Control of Chronic Diseases" and the "Guidance Plan for the Comprehensive Prevention and Control of Chronic Non-communicable Diseases". County CDC provides technical guidance and training to grassroots medical and health institutions not less than 4 times a year, and medical institutions provide technical guidance and training to grassroots medical and health institutions not less than 4 times a year. Chronic disease prevention and control personnel at all levels receive at least two provincial and municipal trainings every year.

Five, the organization work supervision and evaluation.

In order to continuously improve the quality of prevention and control of chronic diseases in our city, and timely discover and correct the problems existing in the work, the CDC of all districts and counties should regularly assess, supervise and inspect the prevention and control of chronic diseases in township and community medical and health institutions, and the CDC of the city should supervise the districts and counties once every six months, and give timely feedback to the supervised units.

Work plan for prevention and treatment of chronic diseases 4 I. Work objectives

4. On the basis of community health service centers (stations), starting with prevention by prevention and individual prevention, explore the management evaluation of CDC in * * District. General hospitals assist in diagnosis, individualized treatment and provide technical support. Community health service centers (stations) follow up and manage hypertension and diabetes.

6. Establish a standardized computer file management system for hypertension and diabetes.

Second, the filing work objectives

1. Establish health records of community residents, and the baseline survey rate of community service population is over 40%;

2. Establish health records of patients with hypertension and diabetes, with follow-up records, treatment records and health education records.

Third, the goal of hypertension work

1, find and register at least 100 hypertensive patients;

2. Discover and register at least 20 high-risk groups;

3.50% of the high-risk population measured their blood pressure at least 1 time every year;

4. The intervention of high-risk groups is recorded and the effect is evaluated;

5.60% residents over 35 years old have their blood pressure measured at least 1 time within 3 years;

6. The awareness rate of hypertension prevention knowledge among residents is 60%.