关键词: 互联网+ ；慢性病管理；健康教练技术

Abstract: Objective: To establish E-coach chronic care model from hospital to home, which integrates the traditional health coaching technology with Internet, and to investigate its feasibility and effects in the management of hypertension. Methods: The E-coach chronic care model was established on the basis of literature review and experts focus group interviews. E-coach chronic care model was performed on outpatients with hypertension, and the blood pressure control rate, medication compliance and participation of offline chronic disease management activities were compared between the E-coach chronic care model group and the routine management group. Results: The blood pressure control rate of patients in the E-coach chronic care model group increased from 27.5% to 61.8% after intervention, which was significantly higher than that of the routine management group (P<0.05). During the intervention period, the participation rate of offline chronic disease management activities in the E-coach chronic care model group was 72.7%, which was higher than that of the routine management group (35.3%), and there was no significant difference in medication compliance between the two groups (P>0.05). Conclusion: The E-coach chronic care model is benefit to improve the control rate of blood pressure and the participation of chronic disease management activities for patients with hypertension and is worthy of clinical application.

Key words: Internet Plus; chronic disease management; health coaching techniques