The integration of medical care and prevention is an important measure for the implementation of the Healthy China Strategy. Family doctor teams as the mainstay and chronic disease management as the entry point are important tools for the implementation of the medical and preventive integration in primary health institutions.

To understand the current situation and obstacles of the integration of medicine and prevention in chronic disease management in Beijing urban areas, so as to provide a basis for decision-making on sustainable development of the medical and preventive integration services.

From December 2023 to February 2024, the purposive sampling was used to invite 20 participants, including the members of the family doctor teams and primary care managers working on the the medical and preventive integration and the chronic disease management in 12 primary health institutions in the urban area of Beijing, to conducted semi-structured interviews focus on the content, division of labour, resource allocation, and existing problems of above services. Thematic analysis was used to analyse and generalise the interview data.

Although the primary health institutions had explored a variety of service modalities to promote the implementation of the integration of medical care and prevention. The qualitative research showed that the main body of the current service was still the general practitioner and the community nurse, and continued the kernel of the chronic disease management service, with the content of the service yet to be innovated, and the service process of pre-consultation, consultation, and post-consultation yet to be promoted. In terms of the operating environment, there were insufficient members of the family medicine team, heavy workload, emphasis on "quantity" rather than "quality" in assessment and evaluation, "information silos", lack of top-level design, and lack of a special funding mechanism. The phenomenon of "medical and prevention fragmentation" is obvious, with the existence of "two lines" of the management systems, "two disconnections" between the main bodies, and regional dispersion of work areas of the medical and preventive integration.

Due to insufficient resources allocation and optimisation of the operation mode, it's necessary to strengthen talent training, reinforce medical insurance support, accelerate information sharing within the region, improve assessment and evaluation mechanisms, as well as strengthen the top-level design, clarify the service pathway, implement community functions, and form a replicable and scalable integrated service model with the participation of the government, community, hospitals and patients.

医防融合是践行健康中国战略的重要举措，应以家庭医生团队为载体、以慢性病管理为切入点强化基层医防融合。

了解北京市城区家庭医生团队开展慢性病医防融合服务现状及在推进过程中面临的阻碍，以期为推动基层医防融合的可持续发展提供依据。

于2023年12月—2024年2月，采用目的抽样法，在北京市城区12家基层医疗卫生机构抽取从事慢性病医防融合工作的家庭医生团队成员及机构管理者共20名，围绕慢性病医防融合服务内容、分工、资源配置、现存问题等开展半结构化访谈，采用主题分析法对访谈资料进行分析与归纳。

定性研究共提炼出4个主题，14个子主题。在服务运行模式方面，尽管北京市城区基层医疗卫生机构面向社区全人群探索多种服务方式促进慢性病医防融合的实施，但当前服务主体仍为全科医生和社区护士，且延续慢性病管理服务内核，服务内容有待革新，诊前-诊中-诊后的服务流程有待推广。在服务运行环境方面，存在家庭医生团队成员不足、工作量大、考核评价重"量"轻"质"、"信息孤岛"、顶层设计欠缺、缺乏专项筹资机制等问题。同时，"医防割裂"现象明显，表现为医防管理体系"两条线"、医防服务主体"两脱节"、医防工作区域分散等。

基层医防融合服务资源配置不足，服务运行模式尚待优化，需加强人才培养，强化医保支撑，加快区域内信息互通，完善考核评价机制。同时，还需加强顶层设计，明确服务路径，落实社区职能，形成卫生行政部门、社区、医院及患者多方参与的可复制、可推广的慢性病医防融合服务模式。