关键词: 慢性病；个案管理；个案管理门诊；管理成效

Abstract: Based on the background introduction and construction of the case management clinic in our hospital, this paper focuses on case collection, case management, closure and information system establishment related to its operation process. Through multidisciplinary integration and joint care, case management clinic service has significant effects in improving patients' satisfaction of hospital services and their self-management ability and compliance. It can provide more comprehensive treatment and care for patients with chronic diseases, improve their qualities of life, reduce medical costs, as well as expand the functions and scope of nursing, which will provide more direction for career development of nursing staff. Thus it is worth learning and promoting in chronic disease management.

Key words: chronic diseases; case management; case management clinic; management effectiveness