| [Objective]To build a "hospital-community-family"-based hypertensive management model to realize the function of hospital-community-family participation in the management of hypertension,and to achieve the goal of grading diagnosis and treatment and overall management.Combining the hospital's existing business system and the entrance of the "Nanjing Hospital of Chinese medicine" WeChat public number,the "Hospital-Community-Family" trinity hypertension management service platform was constructed as a hypertensive management tool to provide patients with a convenient and efficient online medical services,including multi-port patient information collection and sharing,hypertension grading management,individualized consultation and guidance,message alerts,real-time monitoring,two-way referral and other functions.Establish a multi-disciplinary team of medical,nursing,pharmaceuticals and information to participate in the management of hypertension,and initially verify the management effect of this model on hypertensive patients.[Methods]1.Build a "Hospital-Community-Family" Trinity Hypertension Network Management Solution(1)Identifying the division of labor,functional positioning,management methods,and effect evaluation of different levels of "hospital-community-family" through literature research,and combining the "Chinese Hypertension Prevention Guidelines(2010 Edition)","Chinese Hypertension Guidelines for Grassroots Management(2014 Revision)","Chinese Hypertension Patient Education Guide" and "Technical Specifications for Hypertension Chinese Medicine Health Management(Trial Implementation)" determine the management level,management frequency,and management contents,and initially form a network management plan for hypertension.(2)Through structured interviews with patients with hypertension,to understand and explore the attitude of a patient to the hospital and the community to manage their blood pressure;The patient's acceptance of high blood pressure treated by Traditional Chinese Medicine method;Network status of hypertension patients,feasibility and precautions for using the Internet for disease management.From the perspective of the patient,it provides operational and targeted guidance and basis for network management,and finally forms an online and offline combined hypertensive network management solution.2.Establishing a network management platform based on the WeChat public number of "Nanjing Hospital of Chinese medicine"Researchers eventually formed the hypertensive network management plan in the form of a plan to organize a detailed design,detailed description of the contents of each module,implementation methods and requirements.In collaboration with information technology professionals to established a trinity hypertension network management platform based on the "Nanjing Hospital of Chinese medicine" WeChat public number.Researchers were responsible for content testing.3."Hospital-Community-Family" Trinity Hypertension Network Management Pre-Experimental StudyNinety-seven cases of hypertensive patients who met the criteria were randomly divided into intervention group(n=35)and control group(n=32).Patients in the intervention group received three months of WeChat platform management.Before the intervention and 3 months after the intervention,the blood pressure and treatment compliance were evaluated and compared with the control group.[Results]1.Build a "Hospital-Community-Family" Trinity Hypertension Network Management Solution(1)Based on literature research,the construction of the WeChat management platform is based on the chronic care model,with reference to the six elements of the chronic disease care model for comprehensive system management,through the hospital WeChat public number service as an entrance,with the help of the hospital's existing Smart medical platform to develop the "Hospital-Community-Family" Trinity to participate in the hypertension WeChat management platform.The platform implements three major functional modules,respectively for the management program module,management task module and management execution module:The management program module mainly defines the contents of hospitals,community management and the division of labor,function positioning,management contents,management methods,effect evaluation and patient self-management schemes of different levels;Management task modules,mainly including system management,daily Management,interactive communication,data storage and inquiries;Management execution module,mainly to achieve intelligent assessment,intelligent judgment,intelligent disposal of the function,can provide individualized management program and set up early warning tips,to facilitate the timely treatment of both doctors and patients.Hospitals-communities-family are authorized to share medical records with each other,and they are linked together and managed together.They are led by tertiary nurse specialists and establish supervision and guidance bridges for patients and communities.At the same time,using the technical advantages of the three-tiered Chinese Hospital,the characteristics of Chinese medicine are highlighted on the platform's management content,and integrated management of Chinese and Western medicine is conducted.(2)The results of the interviews showed that the patients' recognition of the WeChat management platform is relatively high,and the construction of the hypertensive network management platform is feasible.At the same time,the platform management plan should be set to meet the individual needs of the patients.2."Hospital-Community-Family" Trinity Hypertension Network Management Pre-Experimental Study(1)Blood pressure:After intervention for 3 months,the mean systolic blood pressure of the intervention group was decreased by 8.143 mmHg(95%CI:5.101 to 11.185)from baseline,and the average diastolic pressure was decreased by 3.886 mmHg(95%CI:1.297 to 6.475)from the baseline.In the control group,the mean systolic blood pressure decreased by 6.594 mmHg(95%CI:1.890-11.297)from baseline,and the mean DBP decreased by 4.688 mmHg(95%CI:-0.017-9.392)from the baseline;Among them,the average systolic blood pressure in the intervention group was 1.549mmHg lower than that in the control group;the average diastolic blood pressure in the control group was 0.802 mmHg lower than that in the intervention group.There was no significant difference in blood pressure changes between the two groups(P>0.05).(2)Compliance with hypertension treatment:After intervention for 3 months,the average score of adherence to hypertension treatment in the intervention group was increased by 18.11 points from baseline,and the mean score of compliance of hypertension treatment in the control group was increased by 8.5 points from baseline.The intervention group increased 9.61 points more than the control group.There was statistically significant difference in the change of the compliance of hypertension treatment between the two groups(P<0.05).(3)Evaluation of platform use:Most patients have positive attitude and satisfaction with the use of the platform.Among them,9 patients put forward some opinions or suggestions on the use of the WeChat platform.The content includes concealing personal information of patients(2 persons),increasing communication modules among patients,and placing commonalities of problems encountered by everyone on the elite posts for everyone to learn(4 people).According to the actual situation of the patient,if it is not possible to control the intake of oil and salt in the diet through self-cooking,a specific and practical management method should be developed and pushed to the corresponding population(3 persons).All medical personnel are positive about this management model.They believe that the platform's simple and intelligent management and early-warning model can enhance the medical staffs management of chronic diseases such as hypertension.At the same time,online communication can not only create more management plans for patients to meet their own needs,improve patient satisfaction,and increase the trust of doctors and patients.In the long run,it will also be beneficial to improve the patient's awareness of hypertension,treatment rate and control rate.[Conclusions]From the perspective of literature analysis and patient needs,this study constructed the "Hospital-Community-Family" trinity platform for hypertensive WeChat management,giving full play to the advantages of TCM-specific therapies in the management of hypertension,and led by the hospital's specialist nurses to coordinate the relationship between the hospital,community and patients,provide patients with convenient and efficient online medical services,including multi-port patient information collection and sharing,hypertension grading management,and intelligent medication Remind,on-line individualized guidance,data analysis and processing,and other functions enable more patients with hypertension to visit and manage at the grassroots level and optimize the allocation of medical resources.After preliminary verification,the management of WeChat platform based on the chronic care model is applicable to hypertensive patients.This model has certain management effects on improving blood pressure and treatment compliance,but its long-term effect remains to be further studied and confirmed. |
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