Abstract:

Chronic diseases have become a major public health issue that seriously affects people's health. In China, chronic disease prevalence is increasingly serious as population aging progresses, which poses great challenges to the management of chronic diseases. Chronic disease management in rural primary care is a weak part of domestic chronic disease management, the improvement of which will contribute to the achievement of goals of healthy China and rural vitalization. We performed comparisons between three foreign typical chronic disease management models (chronic care model, innovative care for chronic conditions framework, chronic disease self-management program) , and between three domestic typical ones (chronic disease self-management model, community general practice chronic disease health management model, Xiamen "three division co management" chronic disease management model) , in terms of features, service providers, merits and limitations. On this basis, we proposed recommendations on improving rural chronic disease management in China from four aspects: talent team building, multi-sectoral cooperation, government responsibility, and patient self-management.

Key words: Chronic diseases, Disease management, Management model, Rural

摘要：

慢性病已经成为严重影响居民健康的重大公共卫生问题，随着我国人口老龄化的加剧，慢性病患病形势更加严峻，给慢性病管理带来了巨大挑战。农村基层是我国慢性病管理的薄弱环节，做好农村基层慢性病管理有助于实现"健康中国"战略和"乡村振兴"战略。本文主要介绍了3种国外经典慢性病管理模式（慢性病照护模式、创新型慢性病照护框架、慢性病自我管理计划模式）和3种国内经典慢性病管理模式（慢性病自我管理模式、社区全科慢性病健康管理模式、厦门"三师共管"慢性病管理模式），并从特点、服务提供方、优缺点等方面对各管理模式进行比较，在此基础上从人才队伍建设、多部门合作、政府责任、自我管理4个方面提出完善我国农村地区慢性病管理的对策建议。

关键词: 慢性病, 疾病管理, 管理模式, 农村