Multimorbidity has become an important characteristic of chronic diseases, jeopardizing the health of middle-aged and older adults, and posing new challenges to health management of chronic disease. There is a lack of guidelines and intervention programs for multimorbidity in China. In this study, we initially formulated a health management service pathway for multimorbidity among middle-aged and older adults in the community through the literature research method and focus group discussion method. Then, the constructed service pathway was evaluated and revised through the expert consultation method. Finally, a health management service pathway for the multimorbidity of middle-aged and older adults in the community with behavioral change techniques as the core. The pathway optimizes the implementation of multimorbidity health management, and standardizes its health monitoring, assessment and intervention process, providing a theoretical and practical guidance for primary care providers in the health management of multimorbidity.

多重慢病已成为慢性病发展的重要特征，对中老年人健康产生了严重的危害，也对慢性病健康管理提出了新的挑战。我国现有的慢性病管理实践缺乏对多重慢病的指导意见与干预方案。本研究通过文献研究法、专题小组讨论法初步拟定服务路径。在此基础上，通过专家咨询法对已构建的服务路径进行评价和修订，最终研究编制了以行为改变技术为核心的社区中老年人多重慢病健康管理服务路径。该路径对多重慢病健康管理的实施主体、服务的流程（包括健康监测、评估和干预内容）进行了路径优化，为基层医疗卫生机构服务人员开展多重慢病健康管理提供了理论和实践指导。