Abstract: This paper shows a theme discussion on chronic disease management between several general practice specialists. In the discussion, Prof. ZENG Xue-junthought general practitioner should play the role "Health Gatekeeper" to promote chronic patient centered hierarchical diagnosis and treatment; Director WANG Fanggave her opinion on integrated mode of chronic disease prevention and control in hierarchical medical system; SHA Yue made a point that chronic disease management was a health management from disease to individual; SHEN Qiang analyzed informatization management for chronic disease; YU Guo-yong made an analysis on chronic disease management under integrated traditional and Western medicine; LI Guang-shun presented the challenges of chronic disease management to community health service centers and the corresponding strategies; ZHAO Chun-shan proposed raising national health consciousness and implementing education first; CUI Dian-zhu analyzed how to strengthen chronic disease prevention and control, and develop community health services; ZHAO Hui gave his idea of how to help hierarchical diagnosis and treatment relying on chronic disease management; WANG Hai-long put forward reflections on specialty development of chronic disease prevention and control in community health service centers. The discussion aims to promote effective development of chronic disease management in community health service institutions, explore the working mode of chronic disease management that adapt to the new medical reform, and improve the chronic disease management effects in community health service institutions.

Key words: Chronic disease, Case management, Community health services, Hierarchical diagnosis and treatment, Family doctor contract service

摘要： 本文组织多位全科医学专家对慢性病管理展开主题研讨，曾学军教授认为全科医生应做真正的“健康守门人”，促进以慢性病患者为中心的分级诊疗；王芳主任探讨分级诊疗制度下慢性病防治一体化模式；沙悦提出慢性病管理是从疾病管理到人的健康管理；沈蔷分析信息化支撑下的慢性病管理；于国泳分析中西医结合的慢性病管理；李广顺提出慢性病管理对社区卫生服务中心的挑战和对策；赵春山提示提高全民健康意识，健康教育先行；崔殿柱分析如何加强慢性病防治，发展社区卫生服务；赵辉探讨如何依靠慢性病管理来助力分级诊疗；王海龙分析社区卫生服务中心慢性病防治专科建设思考。旨在促进社区卫生服务机构有效地开展慢性病管理，探索适应新医改的慢性病管理工作模式，提升社区卫生服务机构慢性病管理效果。

关键词: 慢性病, 病例管理, 社区卫生服务, 分级诊疗, 家庭医生签约