A community proactive health management model for family doctors in Shandong, China.

Background Chronic disease management is an essential part of public health management and a fundamental means of slowing down the progression of major diseases. Unlike traditional medical care, proactive health management focuses on the combination of prevention and treatment. Proactive health management can reduce the re-admission rate of patients with chronic diseases, improve long-term prognosis, and effectively reduce the disability and mortality rates of major health events. This study aimed to establish a proactive health management model based on a grid-based medical service team arrangement, and to explore the effect of this model on managing chronic diseases in community health service institutions. Methods A grid-based medical service team was established in Binzhou, Shandong, China, consisting of general practitioners, nurses, public health doctors, health promoters and community grid liaison staff. Each team was responsible for several areas to monitor critical populations within the grid and compile statistics on the health management of these key populations in 2022-2023. Results A total of 2050 patients with coronary artery disease, 4973 patients with hypertension, and 1621 patients with type 2 diabetes were followed up in 2022. Compared with 155,612 resident health records in 2022, the number of records increased by 140.50% in 2023. The number of patients with hypertension under health management in 2023 increased by 50.92%; patients with type 2 diabetes increased by 74.65%; and the number of coronary artery disease increased by 42.00%. After the implementation of grid management, the hospitalisation rate for patients with type 2 diabetes significantly decreased in 2023 (P P >0.05). Conclusion The grid-based community proactive health management model makes full use of the advantages of community resources and improves the pertinence and coverage of community health services. Moreover, it reduces hospitalisation for patients with type 2 diabetes.