Hu Li;Zhang Shanshan;Health Management Department,the Eighty-eighth Hospital of PLA,Taian,Shandong;  

In this paper,the effective path of chronic disease management was explored.We set up a professional chronic disease management team,drew lessons from chronic disease management model,formulated scientific chronic disease assessment system,carried out remote health management,strengthened the education,publicity,supervision,and improved the self management ability of patients with chronic disease.Through a period of chronic disease management,the questionnaire showed that satisfaction was significantly improved,and the chronic disease management path was effective.In a word,monitor-evaluate-intervene-re monitor-re evaluate-re intervene was effective method for chronic disease management.

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