Chronic disease poses a great threat to people's health in China. The chronic disease management is a key area of health work in China. With the development of healthcare reform, health awareness is becoming more and more important. One significant reason that associates with poor population is difficult to get rid of poverty in China is "falling into illness in poverty, staying in poverty due to illness". For winning the tough battle against poverty, anti-poverty programs in health promotion have been formulated and launched by the Central Committee of the Communist of China and the State Council, which is of great significance in facilitating the building of a healthy China, completing the process of building a moderately well-off society in all aspects. In view of the status of domestic chronic disease management and the existed challenges (related programs need to be further developed although some achievements have been made in chronic disease management, lack of a scientific chronic disease management system and a scientific, reasonable and effective chronic disease management evaluation system), based on the review of the status of chronic disease management in foreign countries, from a perspective of customer relationship management (CRM), we developed a chronic disease management system (including information subsystem of chronic disease patients, network-based chronic disease management service subsystem, chronic disease management evaluation subsystem), hoping to improve the domestic chronic disease management (including the management quality and efficiency), and to provide a theoretical basis for policy-makers to formulate targeted policies for precision poverty alleviation.%慢性病对我国居民健康造成较大威胁,慢性病管理工作是我国卫生工作的重点.随着医改的不断深入,健康理念的重要性逐渐凸显,因病致贫、因病返贫,是我国贫困人口难以脱贫的一大重要原因,而实施健康扶贫工程是党中央、国务院关于打赢脱贫攻坚战的决策部署,对于推进健康中国建设、全面建成小康社会具有重要意义.本研究创新性地以客户关系管理(CRM)为基础,通过介绍国内外慢性病管理模式的现状,立足我国慢性病管理实际,提出目前我国慢性病管理仍存在的问题:我国慢性病管理工作已逐步推进并取得一定成效,但仍需进一步落实;缺乏慢性病管理的科学体系;缺少科学、合理及有效的慢性病管理评价系统.针对上述问题,探索在我国健康扶贫视角下基于CRM的慢性病管理体系(慢性病患者信息系统、慢性病服务网络及慢性病管理评价系统),为改善我国慢性病的管理,提高我国慢性病管理的质量与效率以及为我国贫困慢性病患者制定精准的反贫困政策提供理论依据.
展开▼
