chronic diseases
Conditions
Interventions
Experimenta:Establish Interagency services team, and through the team to help the patients with chronic diseases providing continuous, harmonious and integrated health services
Control:The existing service mode
Sponsors
School of Health Policy & Management, Nanjing Medical University, Nanjing, China
Eligibility
Sex/Gender
All
Age
35 Years to 75 Years
Inclusion criteria
Inclusion criteria: 1. The inclusion criteria for patients with Type-2 diabetes(FBG>=7.0mmol/l, PBG>=11.1mmol/l) or hypertension(SBP>=140mmHg, DBP>=90 mmHg) were had received medical service from both CHC physicians and hospital specialists during a 1-year period preceding the day of the survey; 2. Age between 18-50 years old, male and female; 3. Long-term residents who live in the sample areas at least 2 years of (no demolition within 1 year); 4. Without a recent out of local (no demolition plan within 1 year) or long-term (1 year or more) out plan; 5. Patients are register in township hospitals or village clinics' chronic disease management information system, and under the management of chronic diseases; 6. Willing to participate in the study and able to follow instructions, cognitive and have strong ability to accept.
Exclusion criteria
Exclusion criteria: 1. Those with severe diabetic or hypertension complications (e.g., diabetic foot or severe diabetic retinopathy or severe hypertension complications); 2. Diagnosed with secondary hypertension; 3. Those with terminal illness (e.g., with terminal cancer or AIDS); 4. Pregnant or pregnant women, psychopaths.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Blood Pressure Control Rates;Glucose Control Level;Patient Satisfaction;Medical-care-seeking Behavior; | — |
Secondary
| Measure | Time frame |
|---|---|
| Amount of Team Service;Frequency of Internal Training; | — |
Countries
China
Contacts
Public ContactQian Dongfu
Outcome results
None listed