With the intensification of population aging, bone health diseases (e.g., osteoporosis, osteoarthritis, scoliosis) have become a major public health challenge in China. Traditional healthcare models, centered on acute-phase diagnosis and treatment, suffer from shortcomings such as overemphasis on treatment over prevention, fragmented services, and inadequate continuity of rehabilitation, leading to low early screening rates, poor patient compliance, and high recurrence risks. This study analyzes the core characteristics and management bottlenecks of bone health diseases. Drawing on international chronic disease management frameworks and domestic practical experience, and leveraging the resource integration advantages of family doctor contracted services, we innovatively constructed a "smart hierarchical early warning-multidisciplinary collaborative intervention-integrated medical and preventive care" model for full-cycle closed-loop management of bone health, aiming to address systemic challenges in bone health management. The innovation of this study lies in enhancing management efficiency through intelligent tools, optimizing resource allocation via multidisciplinary collaboration, and strengthening the sustainability of healthcare services through policy reforms, thereby providing a systematic paradigm for grassroots bone health management.

随着人口老龄化加剧，骨健康疾病（如骨质疏松症、骨关节炎、脊柱侧凸等）已成为我国重大的公共卫生问题。传统医疗模式以急性期诊疗为核心，存在重治轻防、服务碎片化及康复连续性不足等弊端，导致疾病早期筛查率低、患者依从性差、复发风险高等问题。本研究分析了骨健康疾病的核心特征及管理瓶颈，参照国际慢性病管理模式与国内实践经验，基于家庭医生签约服务的资源整合优势，构建了"智能分层预警-多学科协作干预-医防协同保障"的骨健康全周期闭环管理模式，旨在破解骨健康管理的系统性难题，以智能化工具提高管理效能、以多学科协作优化资源配置、以政策改革强化医疗服务可持续性，为基层骨健康管理提供了系统性范式。