Abstract: With the rapid development of healthcare industry and the advancement of chronic disease prevention，community health management has become an effective measure to strengthen the comprehensive prevention and treatment of chronic diseases.The PRECEDE-PROCEED model is a theoretical model that combines PRECEDE（predisposing，reinforcing，and enabling constructs in educational/environmental diagnosis and evaluation） with PROCEED（policy，regulatory，and organization constructs in educational/environmental development）．Under the guidance of PRECEDE-PROCEED model，this study tried to figure out the influencing factors and existing problems of community health management on chronic diseases with the example of Chebei Community Health Service Center in Tianhe District of Guangzhou.Five modules were systematically evaluated，and the intervention was carried out in five aspects with a comprehensive evaluation from three perspectives.Through multidimensional perspective analysis，this paper tried to put forward corresponding suggestions in order to provide the reference for the innovation and optimization of urban community health management of chronic diseases.

Key words: PRECEDE - PROCEED model, Chronic diseases, Health management

摘要： 在健康服务业快速发展和慢性病预防关卡前移的时代背景下，社区健康管理成为加强慢性病综合防治效果的有效措施。PRECEDE-PROCEED模式是将PRECEDE（教育诊断和评估中的倾向、促成和强化因素）与PROCEED（教育和环境干预中的政策、管理和组织策略）有机结合的理论模式。本研究在PRECEDE-PROCEED模式的指导下，结合广州市天河区车陂街社区卫生服务中心这一实例，从5个模块进行系统评估，5个方面实施干预，3个角度进行全面评价，以多维度的视角分析得出影响社区慢性病患者健康状况的因素和存在的问题，并提出相应的建议，以期为创新和优化城市社区慢性病健康管理模式提供参考和借鉴。

关键词: PRECEDE-PROCEED模式, 慢性病, 健康管理