Abstract: Promoting the delivery of intensive integrated essential medical services and national essential public health services，as well as contracted family doctor services by primary care settings，are important tasks to deepen the reform of the pharmaceutical and healthcare system. To explore an appropriate health management mode for delivering both essential medical services and national essential public health services in primary care，we have tried to provide such services for hypertensive and diabetes patients by a contracted general practitioner team via five integrated measures（integration of management，workforce，scope items，performance assessment，and information of the two types of services）. In this way，the patient could access to both medical services and national essential public health services in an outpatient consultation. This kind of comprehensive health management（consisting of preventive，treatment and management services） is conducive to improving the service quality and residents' sense of gain，as well as promoting the intra-hospital horizontal integration of such services and inter-hospital vertical integration of medical resources.

Key words: Primary health care, Community health services, Health services research, Primary health care institutions, Integration of treatment and prevention, Chronic disease management, Health management service mode, Chongqing

摘要： 推进基层医防深度融合，做实家庭医生签约服务，是深化医药卫生体制改革的重要任务。本文以高血压、糖尿病健康管理为突破口，以家庭医生签约服务为载体，探索基层医防融合健康管理服务模式。通过基层医疗卫生机构内部的“管理融、队伍融、服务融、绩效融、信息融”，实现由全科医生团队统揽医疗和公共卫生服务，做到一次门诊既满足患者诊疗需求，同时也完成必需的基本公共卫生服务。医防“五融合”提供“防、治、管”一体的健康管理，既有利于提升服务质量，增强居民获得感，又有利于推动机构内部横向的基本医疗和基本公共卫生的融合及机构外部纵向的医疗资源整合。

关键词: 初级卫生保健, 社区卫生服务, 卫生服务研究, 基层医疗卫生机构, 医防融合, 慢性病管理, 健康管理服务模式, 重庆