医养随访一体机能帮助哪些人，都怎么帮助的?

一、核心服务群体

1、 Core service group

慢性病患者（高血压、糖尿病等）

Patients with chronic diseases (hypertension, diabetes, etc.)

通过定期自动监测血压、血糖等关键指标，建立动态健康档案，异常数据实时预警，避免病情恶化。

By regularly monitoring key indicators such as blood pressure and blood sugar, establishing dynamic health records, and providing real-time alerts for abnormal data, we can prevent the deterioration of the condition.

提供用药提醒、复诊建议等干预指导，提升治疗依从性。

Provide medication reminders, follow-up recommendations, and other intervention guidance to improve treatment compliance.

术后康复人群

Postoperative rehabilitation population

持续跟踪心率、血氧、活动能力等恢复指标，减少频繁往返医院的负担。

Continuously track recovery indicators such as heart rate, blood oxygen, and activity level to reduce the burden of frequent hospital trips.

远程上传数据至主治医生，实现个性化康复方案调整。

Upload data remotely to the attending physician to adjust personalized rehabilitation plans.

老年群体（尤其独居老人）

Elderly population (especially those living alone)

一键紧急呼叫功能应对突发状况，跌倒检测等安全监测降低意外风险。

The one click emergency call function responds to unexpected situations, and safety monitoring such as fall detection reduces the risk of accidents.

长期健康趋势分析，辅助早期发现认知衰退或慢性病征兆。

Long term health trend analysis to assist in early detection of cognitive decline or signs of chronic diseases.

亚健康及健康管理人群

Sub healthy and Health Management Population

体质检测（如中医辨证、代谢指标）结合生活方式问卷，生成饮食/运动建议。

Combining physical fitness testing (such as traditional Chinese medicine syndrome differentiation and metabolic indicators) with lifestyle questionnaires to generate dietary/exercise recommendations.

定期生成健康报告，推动疾病预防意识。

Regularly generate health reports to promote disease prevention awareness.

二、功能支持与帮助方式

2、 Function support and help methods

智能检测：整合血压计、血糖仪、心电监测等医疗级设备，10分钟内完成多维度健康评估。

Intelligent detection: integrating medical grade equipment such as blood pressure monitors, blood glucose meters, and electrocardiogram monitoring, completing multi-dimensional health assessments within 10 minutes.

数据互联：检测结果自动同步至家庭医生或家属端，支持远程会诊与及时干预。

Data interconnection: The detection results are automatically synchronized to the family doctor or family member's end, supporting remote consultation and timely intervention.

宣教干预：内置视频指导慢性病自我管理，推送定制化健康知识（如低盐食谱、康复训练）。

Educational intervention: Built in video guidance for self-management of chronic diseases, pushing customized health knowledge (such as low salt diets, rehabilitation training).

资源对接：异常数据触发社区医护上门随访，或转诊至协作医院，形成分级诊疗闭环。

Resource docking: Abnormal data triggers community medical visits or referrals to collaborative hospitals, forming a hierarchical diagnosis and treatment loop.

三、社会效益

3、 Social benefits

对个人：减少无效就诊频次，降低突发健康事件风险。

For individuals: reduce the frequency of ineffective medical visits and lower the risk of sudden health emergencies.

对家庭：缓解照护压力，尤其帮助异地子女实时掌握父母健康状况。

For families: relieve caregiving pressure, especially helping children from other places to keep track of their parents' health status in real time.

对医疗机构：优化基层服务效率，将有限资源聚焦高危人群管理。

For medical institutions: optimize the efficiency of grassroots services and focus limited resources on managing high-risk populations.

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