关键词: 医联体, 分级诊疗, 慢性病管理, 专全结合

Abstract: The distribution of medical resources in China is imbalanced nowadays. Most high-quality medical resources are distributed in tertiary hospitals，but not in primary healthcare institutions. Insufficient resources hinder primary healthcare institutions from playing their due role in promoting the development of the hierarchical medical system，to satisfy the health needs of residents. Therefore，the supply-side reform in pharmaceutical and healthcare fields is imperative. The "Healthy China 2030" Planning Outline put forward goals for realizing the innovation of the patterns of healthcare provision and achieving a mature and sound hierarchical medical system in an all-round way. The construction of a medical consortium is a way to promote the development of hierarchical medical system by integrating the local medical resources and allocating high-quality resources to primary care using a guided approach. We analyzed the structure of chronic disease management teams of medical consortium of Beijing Chao-Yang Hospital，Capital Medical University，consisting mainly of specialists from general hospitals，general practitioners and health managers from community healthcare institutions，detailed the teams' delivery process of contracted family doctor services，summarized the teams' features and positive role in promoting the development of hierarchical medical system，with a view to providing a reference for facilitating the full implementation of this system.

Key words: Medical health alliance, Hierarchical medical system, Chronic disease management, Specialist physicians-general practitioners combination