What is it about?

At present, more patients suffer from multiple chronic diseases. However, the hospital's existing chronic disease management is carried out according to the department.This means that a patient needs to go to more than one department for a chronic disease treatment.How to explore and develop an efficient model of chronic disease management that is suitable for West China Hospital of Sichuan University is the theme of this study.This study focuses on investigating the continuous care management model of multiple departments and chronic diseases in West China Hospital of Sichuan University by performing an empirical study of chronic disease management service system based on several perspectives associated with chronic disease management.

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Why is it important?

This model has a practical value in improving the quality of chronic disease management service delivery system in large hospitals.


Patients with chronic disease have many complications and a long course of disease, which will generate a large amount of health data. However, the current follow-up mechanism is not perfect, the follow-up system is weak, and a large part of patients are followed. The health data of patients cannot be fully grasped by medical staff, which can easily lead to the disconnection of chronic disease management process. Multi-channel collection and feedback of patients' health data should be performed, a set of standard process for multi-channel management of patients with chronic diseases' health data should be developed, and the working process should be continuously optimized to improve work efficiency.

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Read the Original

This page is a summary of: Elements of chronic disease management service system: an empirical study from large hospitals in China, Scientific Reports, April 2022, Springer Science + Business Media,
DOI: 10.1038/s41598-022-09784-8.
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