Chronic disease management in community:challenge and strategy / 中华全科医师杂志

ABSTRACT

In a survey on chronic disease management in Xujiahui Community,we found that the general practice team was facing the following problems：①Heavy burden of follow-up work by a relatively smaller number of physicians;②Misunderstanding of health and insufficient recognition of the importance of chronic disease management among community residents;and③Delayed database construction and inefficient performance.In this study,we described the strategies to improve chronic disease management in communities.