The report of the 20th National Congress of the Communist Party of China pointed out that it is necessary to adhere to prevention, strengthen the health management of major chronic diseases, and improve the grassroots ability to prevent and treat diseases and health management. Faced with the dual challenges of high incidence of chronic diseases and emerging infectious diseases, the traditional mode of "emphasizing treatment and neglecting prevention" has been difficult to meet the growing health needs of the people. Jiangxi Province issued Several Opinions on Accelerating the Modernization of Health and Health and Action Plan for Building a New Era of Health and Health in Jiangxi Province (2024-2027), integrating health and health modernization into the province's development strategy and formulating a series of institutional measures.

Focusing on the management of major chronic diseases, this study systematically analyzed the main trends of the current integration of medical and prevention, and explored the five major challenges faced by the current management of chronic diseases: the imbalance of supply and demand of policy tools, the lack of coordination between management departments, the lack of cooperation between departments, the uneven guarantee of talents, and the lack of self-management enthusiasm of patients.

According to the practical experience of some provinces and cities in China, the "1+2+3" model in Yichun, the "hospital management" model in Jiujiang, the "project + grid" model in Pingxiang and the "Project + grid" model in Shangrao Wuyuan were put forward.

The research has identified four representative chronic disease management models in Jiangxi Province: (1) The "1+2+3" integrated management model in Wan County, Yichun City, which uses family doctor contracting as the link to establish a closed-loop service system for prevention, diagnosis and rehabilitation; (2) The "hospital-run and hospital-managed" traditional Chinese medicine (TCM) characteristic prevention and treatment model in Jiujiang City, where public hospitals directly manage community health centers to achieve a deep integration of TCM applicable technologies and chronic disease prevention and control; (3) The close-knit medical consortium model in Pingxiang City, which relies on the three-level linkage of districts, towns and villages and information support to promote the downward flow of high-quality resources and the simultaneous management of chronic diseases; (4) The "project + grid-based" model in Wuyuan County, Shangrao City, with the H-type hypertension prevention and control project as the starting point, to build a chronic disease prevention and control network led by the government, with coordinated efforts from various departments and grid-based management. Further, four implementation paths for the integration of medical care and prevention of chronic diseases in Jiangxi Province have been condensed: coordinated governance of the system, refined integrated management, diversified TCM empowerment, and efficient linkage of medical consortia.

Jiangxi Province has initially established a replicable and scalable multi-mode approach in promoting the integration of medical care and prevention for chronic disease management. However, it still faces issues such as imbalance between policy supply and demand, poor cross-departmental collaboration, insufficient talent support, and weak patient self-management awareness. In the future, efforts should be made to improve the overall planning, strengthen policy coordination, optimize the integrated medical and prevention mechanism, leverage the advantages of traditional Chinese medicine, and provide information support. These measures aim to promote the high-quality development of the chronic disease management system and contribute to achieving the goal of modernizing health care in Jiangxi Province.