The invention relates to a three-specialist co-management graded diagnosis and treatment transfer
treatment system and method for
chronic disease. According to the
system and method, the '1+1+X' management mode is creatively provided, in other words, a specialist physician, a general
medical practitioner and multiple health managers make up a management team. A three-specialist co-management
service mode is established under the '1+1+X' management mode. Firstly, the
chronic disease specialist physician conducts diagnosis and complication screening on a patient and makes an
individualized treatment and management scheme; the general
medical practitioner is required to conduct daily
disease condition management of the patient, monitor the implementation condition of the treatment scheme and get in touch with the specialist physician when the
disease condition changes or relapses so that
medical treatment instructions can be obtained; the health managers are required to implement the management scheme prepared by the specialist physician, conduct routine visit and
health education and the like. By means of the three-specialist co-management graded diagnosis and treatment transfer
treatment system and method, the patient can be transferred to a lower-grade
community hospital, the patient with the
disease condition stable is encouraged to conduct
self management, and the pressure of departments of an upper-grade hospital is alleviated.