1) Risk factor discovery

根據(jù)《全國(guó)慢性病預(yù)防控制工作規(guī)范（試行）2011版》第四章“干預(yù)與管理”中指出：慢性病高風(fēng)險(xiǎn)人群為具有以下特征之一者：

According to Chapter 4 "Intervention and Management" of the "National Norms for Chronic Disease Prevention and Control (Trial) 2011 Edition", it is pointed out that high-risk individuals with chronic diseases are those with one of the following characteristics:

（1）血壓水平為130-139/85-89mmHg；

(1) The blood pressure level is 130-139/85-89mHg;

（2）現(xiàn)在吸煙者；

(2) Current smokers;

（3）空腹血糖水平為：6.1 ≤ FBG<7.0mmol/L；

(3) The fasting blood glucose level is 6.1 ≤ FBG<7.0mmol/L;

（4）血清總膽固醇水平為：5.2 ≤ TC<6.2mmol/L；

(4) The serum total cholesterol level is 5.2 ≤ TC<6.2mmol/L;

（5）男性腰圍≥ 90cm，女性腰圍≥ 85cm。

(5) Male waist circumference ≥ 90cm, female waist circumference ≥ 85cm.

針對(duì)具有3 項(xiàng)及以上特征者，應(yīng)當(dāng)納入個(gè)體健康管理范圍

Individuals with three or more characteristics should be included in the scope of individual health management

2) 慢病監(jiān)測(cè)與管理

2) Chronic disease monitoring and management

社區(qū)衛(wèi)生服務(wù)中心（站）都在開展以“高血壓”、“糖尿病”、“冠心病”、“腦卒中”、“惡性腫瘤”為重點(diǎn)的慢病性規(guī)范化管理工作，“健康小屋”的建設(shè)應(yīng)能對(duì)這部分重點(diǎn)人群提供規(guī)范化管理的輔助作用，比如定期的高血壓測(cè)量、血糖測(cè)量有助于及時(shí)掌握高血壓患者、糖尿病患者控制效果，及時(shí)發(fā)現(xiàn)并進(jìn)行指導(dǎo)。

Community health service centers (stations) are carrying out the standardized management of chronic diseases focusing on "hypertension", "diabetes", "coronary heart disease", "stroke", and "malignant tumor". The construction of the "health house" should be able to provide the auxiliary role of standardized management for this part of the key population. For example, regular measurement of hypertension and blood sugar will help to timely grasp the control effect of hypertension patients and diabetes patients, Timely discovery and guidance.

3) 健康評(píng)估與指導(dǎo)

3) Health assessment and guidance

健康管理不同于疾病管理，健康管理主要是根據(jù)目前身體狀況，發(fā)現(xiàn)危險(xiǎn)因素，綜合當(dāng)前生活方式，進(jìn)行綜合的評(píng)估，并做出健康促進(jìn)指導(dǎo)，做到早期防預(yù)治未病為主。從“合理膳食、適量運(yùn)行、戒煙戒酒、心理平衡、健康養(yǎng)生”等預(yù)防控制健康基石入手。

Health management is different from disease management. Health management is mainly based on the current physical condition, identifying risk factors, integrating the current lifestyle, conducting comprehensive assessments, and providing health promotion guidance to achieve early prevention, treatment, and prevention of diseases. Starting from the cornerstone of prevention and control of health, such as "reasonable diet, moderate exercise, smoking and alcohol cessation, psychological balance, and health preservation".

4) 公共衛(wèi)生服務(wù)

4) Public health services

社區(qū)可以通過(guò)健康小屋的建設(shè)，可以提高國(guó)家基礎(chǔ)公共衛(wèi)生服務(wù)的質(zhì)量，主要體現(xiàn)在“居民日常健康體檢”、“疾病篩查統(tǒng)計(jì)”、“慢性病防控”“康復(fù)輔助”、“健康教育”、“健康咨詢”、“健康管理服務(wù)”。

The construction of health huts in communities can improve the quality of national basic public health services, mainly reflected in "daily health examinations for residents", "disease screening statistics", "chronic disease prevention and control", "rehabilitation assistance", "health education", "health consultation", and "health management services".

四、健康小屋服務(wù)流程

4、 Health Cabin Service Process

1) 通過(guò)在基層醫(yī)療衛(wèi)生服務(wù)機(jī)構(gòu)、居委會(huì)、街道辦等公共服務(wù)點(diǎn)，部署智能體檢機(jī)，采集居民的健康體征數(shù)據(jù)（身高、體重、血壓、脈率、BMI等），自動(dòng)傳輸至居民健康管理信息平臺(tái)（區(qū)域衛(wèi)生信息系統(tǒng)平臺(tái)），推送至社區(qū)醫(yī)（家庭醫(yī)生）的工作平臺(tái)。

1) By deploying intelligent physical examination machines at public service points such as grassroots medical and health service institutions, neighborhood committees, and street offices, residents' health sign data (height, weight, blood pressure, pulse rate, BMI, etc.) is collected and automatically transmitted to the residents' health management information platform (regional health information system platform), and pushed to the work platform of community doctors (family doctors).

2) 體檢時(shí)，向居民和社區(qū)管理者發(fā)出健康異常指標(biāo)提示。

2) During the physical examination, issue health abnormality indicators to residents and community managers.

3) 社區(qū)醫(yī)生查閱居民的健康體征測(cè)量數(shù)據(jù)，提供相應(yīng)健康指導(dǎo)。可結(jié)合信息平臺(tái)轉(zhuǎn)發(fā)至居民個(gè)人、居民家屬，告知健康狀況。

3) Community doctors consult residents' health sign measurement data and provide corresponding health guidance. It can be forwarded to individual residents and their families through information platforms to inform them of their health status.

4) 居民個(gè)人、居民家屬可登錄相應(yīng)的健康信息平臺(tái)查閱個(gè)人的體征測(cè)量數(shù)據(jù)及健康指導(dǎo)建議。

4) Individuals and family members of residents can log in to the corresponding health information platform to view their physical sign measurement data and health guidance suggestions.

5) 平臺(tái)與區(qū)域的健康檔案系統(tǒng)對(duì)接，補(bǔ)充居民的健康檔案。

5) The platform interfaces with the regional health record system to supplement residents' health records.

6) 區(qū)域管理者根據(jù)信息平臺(tái)數(shù)據(jù)，知曉區(qū)域內(nèi)居民健康信息狀況，為公共衛(wèi)生服務(wù)提供業(yè)務(wù)數(shù)據(jù)。

6) Regional managers are informed of the health information status of residents in the region based on information platform data, and provide business data for public health services.

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