At present, the collaboration of general practice and speciality has been applied to the diagnosis, treatment and management of various chronic diseases in the community based on the technical support of disease diagnosis and treatment and the implementation of hierarchical diagnosis and treatment. Based on the patient-centered, systematic and holistic thinking characteristics of general practice, the general practice team of Yangpu Hospital Affiliated to Tongji University explored and practiced a more comprehensive, in-depth and effective collaboration model of general practice and speciality around the multi-dimensional construction of 'six ones'. The construction of 'six ones' was based on the collaboration of general practice and speciality between general hospitals and community health service centers. Taking osteoarthritis (OA), a common chronic disease in the community, as an example, its contents and characteristics were as follows. (1) Establishment of a multidisciplinary team: the established team could rely on the basis of the three-dimensional integrated health care system of the general hospitals, to give play to the liaison and coordination role of general practice department in general hospitals, refine and coordinate the multidisciplinary division of labor; (2) Improvement of a set of diagnosis and treatment processes: improve a set of hierarchical diagnosis and treatment process for diseases based on scientific evidence, and evaluate the effectiveness of the diagnosis and treatment process, so that it could help to improve patients' symptoms and quality of life; (3) Development of an APP: the developed APP could cover multiple functions such as hierarchical diagnosis and management of OA patients, doctor-patient communication, popularization of science, appointment registration, and could record the complete diagnosis and treatment data in the exclusive information platform; (4) Designing a set of publicity and promotion programs: Publicize the program in multiple scenarios such as disease diagnosis and treatment, health examination and consultation in general hospitals and communities through a variety of forms of text, pictures and videos; (5) Establishment of a case database: establish a specific disease database for OA patients, continuously follow up patients and implement hierarchical management of the collected data, so as to provide more cases with general characteristics; (6) Construction of a set of curricula: the curriculum is built around OA specialties, including "bone pain as an undifferentiated disease in general practice" and "chronic disease management of OA", the course is conducted in the form of problem-oriented learning, outpatient consultation and teaching round demonstration, which was for multi-level training of undergraduate, graduate and continuing education. Taking the 'six ones' construction of OA management in the community as an example, the practice of the collaboration of general practice and speciality for the management of chronic disease based on the thinking of general practice suggests the potential of comprehensive, in-depth cooperation and mutual promotion between the two sides in multiple dimensions of medicine, teaching and research, as well as the effectiveness of optimizing and integrating the team, technology and information support related to hierarchical disease management for promoting the physical and mental health of patients.

全科与专科协作的"全专协作模式"目前主要基于疾病诊治技术支持、分级诊疗落实等内容被运用于对社区各类慢病的诊治和管理。同济大学附属杨浦医院全科医学团队基于全科医学思维"以患者为中心""系统观和整体观"的特点，围绕"六个一"进行多维度建设，探索和实践更为全面、深入及有效的全专协作模式。"六个一"的建设基于综合性医院与社区卫生服务中心的全专协作，以对社区常见慢病骨关节炎（OA）为例，其内容和特点包括：（1）成立一个多学科团队：所成立诊疗团队能依托综合性医院层面三维协同医联体基础，发挥综合性医院的全科联络协调作用，细化协调多学科分工；（2）完善一套诊治流程：遵循科学循证完善一套疾病的分级诊治流程，并对诊治流程进行成效评估，使其更有助于改善疾病症状，提高患者生活质量等；（3）开发一个APP：所开发APP能涵盖对OA患者的分层诊疗和管理、医患沟通、科普推送、预约挂号等多种功能，并可将完整诊疗数据收录于专属信息平台；（4）设计一套宣传推广方案：通过文字、图片和视频等多种形式，在综合性医院及社区的疾病诊疗、健康体检和咨询等多场景下进行宣传；（5）建立一个案例库：建立OA患者专病案例库，持续随访患者并将收集到的数据实行分层管理，以便于提供更多全科特色案例；（6）建设一套课程：围绕OA专病建设的课程内容包含"全科骨痛未分化疾病""骨关节炎慢病管理"，开展形式包括以问题为导向的学习、门诊接诊和教学查房示范等，用于全科本科、研究生和继续教育的多层次教学培训。以社区骨关节炎管理的"六个一"建设为例，基于全科医学思维的全专协作慢病管理实践提示全科与专科有在医、教、研多维度全面深入合作和相互促进的潜力，且优化整合疾病分级管理相关的团队、技术、信息支持等对于促进患者身心健康水平提升效果良好。