China is one of the countries with the fastest growing prevalence of diabetes in the world, and also has the largest number of people with diabetes. The "Health China 2030" plan clearly proposes to further prevent and control major diseases, implement diabetes prevention and control, and guide patients with diabetes to strengthen health management and delay or prevent the development of diabetes. In the past 20 years, value co-creation theory has been well developed in the field of health services, and different countries (regions) have explored programs to prevent and control diabetes at low cost and high effectiveness, but it is currently lacking in the field of chronic disease management in China. Based on the perspective of value co-creation, this paper further summarizes the domestic and international experience of chronic disease management taking community as the research and analysis point, proposes the prospect from four aspects of active health, organizational guidance, digital technology, and incentive assessment, which provides references for optimizing and improving the service system of diabetes management at primary health care, establishing a model of collaborative participation of multiple subjects in community chronic disease management based on value co-creation, and realizing co-creation, co-management and sharing of chronic disease management.