Chronic disease management refers to the medical behavior and process of regular testing, continuous monitoring, evaluation and comprehensive intervention management of chronic non-communicable diseases (such as hypertension, diabetes, cardiovascular and cerebrovascular diseases, etc.) and their risk factors. Its main content includes early screening of chronic diseases, chronic disease risk prediction, early warning and comprehensive intervention, as well as comprehensive management of chronic disease populations and evaluation of the effectiveness of chronic disease management. The following is a detailed summary of chronic disease management:
I. Objects of chronic disease management

Chronic non-communicable diseases: such as hypertension, diabetes, cardiovascular and cerebrovascular diseases, etc.
Chronic disease patients:
Patients' cognition of their chronic diseases.
Patients' negative psychological state caused by their chronic diseases.
Patients' behaviors related to their chronic diseases.
Social environment of chronic disease patients:
Micro social environment: family environment, work environment, peer group, community environment and health service environment, etc.
Macro social environment: the class of the patient, the relationship between social classes and the way the social class structure changes, etc.

2. Basic methods of chronic disease management

Self-management:
Individuals prevent and control the occurrence of chronic diseases by developing good living habits, eating habits, exercise habits, etc. For example, regular aerobic exercise, such as jogging, swimming, and mountain climbing, can help enhance the body's immunity, control weight, and reduce the risk of chronic diseases.
Regular physical examinations:
Going to the hospital for regular physical examinations can help detect chronic diseases early and take measures for treatment and intervention as early as possible. For example, a full physical examination is conducted once a year, including indicators such as blood pressure, blood lipids, and blood sugar.
Drug treatment:
Taking drugs for treatment under the guidance of a doctor can help control the condition and prevent the disease from worsening.
Comprehensive intervention:
The intervention team should at least consist of doctors and nurses responsible for biomedical intervention, psychologists responsible for psychological intervention, and social workers responsible for social environment intervention.
Use group work methods, community work methods, and policy evaluation methods to conduct comprehensive interventions on chronic disease patients.

3. New Models and Trends in Chronic Disease Management

"Internet +" Medical Services:
Utilize big data, cloud services, and smart devices combined with chronic disease management to create a new model of "Internet + chronic disease management". For example, provide online consultation, medical consultation, medical records, health assessment and other services.
"Internet +" Family Doctor Contract Service:
Connect residents with grassroots health institutions through WeChat platforms, etc., and provide online diagnosis and treatment and family doctor contract services.
"Internet +" Intelligent Management of Chronic Diseases:
Deploy smart wearable devices, and family doctors implement online monitoring and management, and simultaneously establish a multi-level monitoring platform to achieve "all-weather health monitoring, full-process abnormal alarm, full-time remote diagnosis" services.
Insurance Intervention:
Together with e-commerce circulation, AI, big data, out-of-hospital App terminals, offline pharmacies, health management centers, etc., a grand chronic disease management panoramic team is formed.
Digital Therapy:
Use highly intelligent medical software to drive the prevention, treatment and management of specific diseases, improve patient compliance, and help users develop good health behavior habits.

IV. Evaluation of the effectiveness of chronic disease management

Evaluate the effectiveness of chronic disease management, including the improvement of patients' health status, the reduction of medical expenses, and the improvement of patients' quality of life, so as to continuously optimize chronic disease management strategies and methods.

In summary, chronic disease management is a complex and systematic project that requires the joint efforts of patients, doctors, social workers, etc., adopting comprehensive intervention methods, combining new technologies and new models, and continuously improving the effectiveness and quality of chronic disease management.