Abstract: Based on the "1+1+1" hierarchical contractual service delivery mode implemented in Shanghai，Weifang Community Health Service Center（WCHSC） and Renji Hospital，Shanghai Jiaotong University School of Medicine（RHSJUSM） co-developed a general-specialty hierarchical management mode for chronic heart failure（CHF）．This mode of care is co-delivered by both WCHSC（offering primary care） and RHSJUSM（offering specialty care） in Renji-Weifang CHF Studio in WCHSC，using the co-developed CHF hierarchical diagnostic and treatment criteria（based on NYHA functional class，body weight changes，and BNP or NT-proBNP），and referral procedure，under the conditions of sharing drugs，as well as laboratory test results for CHF.We detailedly introduced both the theory and implementation of general-specialty hierarchical management mode for CHF，and put forward that，using this mode is contributive to the appropriate allocation of high-quality medical resources to primary healthcare institutions，to the improvement of GPs' diagnostic and therapeutic ability，and to the identification of the severity of disease in a more simple and effective way.Moreover，during the management，with the help of the full-time assistant in monitoring weight and consecutive self-management，the self-management compliance of patients can be improved.This mode is helpful to form a hierarchical diagnosis and treatment model characterized by separate treatment of acute and chronic diseases，and cooperation between higher- and lower-level healthcare institutions.

Key words: Hierarchical medical treatment, Contracted family doctor services , Heart failure, General practice

摘要： 基于上海市“1+1+1”签约分级诊疗模式，潍坊社区卫生服务中心与上海交通大学附属仁济医院协同合作，以慢性心力衰竭（慢性心衰）为例，建立慢性心衰“全科-专科”分级诊疗协作管理模式。该模式以设立在社区的“仁济-潍坊”慢性心衰专病工作室为载体，从心功能分级、体质量监测改变、B型利钠肽（BNP）或N末端B型利钠肽原（NT-proBNP）三方面共同制定慢性心衰的分级诊疗标准和转诊流程，同时实现药品和实验室检查的同质化，本文主要介绍其开展模式和初步实施效果。通过“全科-专科”共同管理，一方面实现优质医疗资源适当下沉，提高全科医生的诊疗能力，便于简单有效识别疾病严重程度；另一方面设立专职助理员规范患者体质量监测和连续性管理，提高患者自我管理的依从性，从而有助于形成急慢分治、上下联动的分级诊疗模式。

关键词: 分级医疗, 家庭医生签约服务, 心力衰竭, 全科医学