The report of the 20th National Congress of the Communist Party of China pointed out that it is necessary to adhere to prevention, strengthen the health management of major chronic diseases, and improve the grassroots ability to prevent and treat diseases and health management. Faced with the dual challenges of high incidence of chronic diseases and emerging infectious diseases, the traditional mode of "emphasizing treatment and neglecting prevention" has been difficult to meet the growing health needs of the people. Jiangxi Province issued Several Opinions on Accelerating the Modernization of Health and Health and Action Plan for Building a New Era of Health and Health in Jiangxi Province (2024-2027), integrating health and health modernization into the province's development strategy and formulating a series of institutional measures.

Focusing on the management of major chronic diseases, this study systematically analyzed the main trends of the current integration of medical and prevention, and explored the five major challenges faced by the current management of chronic diseases: the imbalance of supply and demand of policy tools, the lack of coordination between management departments, the lack of cooperation between departments, the uneven guarantee of talents, and the lack of self-management enthusiasm of patients.

According to the practical experience of some provinces and cities in China, the "1+2+3" model in Yichun, the "hospital management" model in Jiujiang, the "project + grid" model in Pingxiang and the "Project + grid" model in Shangrao Wuyuan were put forward.

The research has identified four representative chronic disease management models in Jiangxi Province: (1) The "1+2+3" integrated management model in Wan County, Yichun City, which uses family doctor contracting as the link to establish a closed-loop service system for prevention, diagnosis and rehabilitation; (2) The "hospital-run and hospital-managed" traditional Chinese medicine (TCM) characteristic prevention and treatment model in Jiujiang City, where public hospitals directly manage community health centers to achieve a deep integration of TCM applicable technologies and chronic disease prevention and control; (3) The close-knit medical consortium model in Pingxiang City, which relies on the three-level linkage of districts, towns and villages and information support to promote the downward flow of high-quality resources and the simultaneous management of chronic diseases; (4) The "project + grid-based" model in Wuyuan County, Shangrao City, with the H-type hypertension prevention and control project as the starting point, to build a chronic disease prevention and control network led by the government, with coordinated efforts from various departments and grid-based management. Further, four implementation paths for the integration of medical care and prevention of chronic diseases in Jiangxi Province have been condensed: coordinated governance of the system, refined integrated management, diversified TCM empowerment, and efficient linkage of medical consortia.

Jiangxi Province has initially established a replicable and scalable multi-mode approach in promoting the integration of medical care and prevention for chronic disease management. However, it still faces issues such as imbalance between policy supply and demand, poor cross-departmental collaboration, insufficient talent support, and weak patient self-management awareness. In the future, efforts should be made to improve the overall planning, strengthen policy coordination, optimize the integrated medical and prevention mechanism, leverage the advantages of traditional Chinese medicine, and provide information support. These measures aim to promote the high-quality development of the chronic disease management system and contribute to achieving the goal of modernizing health care in Jiangxi Province.

党的二十大报告指出，要坚持预防为主，加强重大慢性病健康管理，提高基层防病治病和健康管理能力。面对慢性病高发和新发突发传染病的双重挑战，传统的"重治轻防"模式已难以满足人民日益增长的健康需求。江西省出台《关于加快推进卫生健康现代化的若干意见》和《江西省建设新时代卫生健康"四区四高地"行动方案（2024-2027年）》，将卫生健康现代化纳入全省发展战略，制定一系列制度举措。

本研究围绕重大慢性病管理，系统分析当前医防融合的主要趋势，探讨江西省当前慢性病管理面临的五大挑战：政策工具供需不平衡、管理部门协同不足、部门协作不畅、人才保障不均、患者自我管理积极性不足。

结合国内部分省市的实践经验，提出宜春万载"1+2+3"模式、九江"院办院管"模式、萍乡紧密型医共体模式和上饶婺源"项目+网格化"模式，凝练出4种可推广的医防融合路径。

研究总结出江西省4种具有代表性的慢性病管理模式：（1）宜春万载"1+2+3"一体化管理模式，以家庭医生签约为纽带，构建预防—诊治—康复闭环服务体系；（2）九江"院办院管"中医药特色防治模式，通过公立医院直管社区卫生中心，实现中医药适宜技术与慢病防控深度融合；（3）萍乡紧密型医共体模式，依托区、乡、村三级联动和信息化支撑，推动优质资源下沉与慢性病管理同频共治；（4）上饶婺源"项目+网格化"模式，以H型高血压防控项目为抓手，构建政府主导、部门协同、网格化管理的慢病防控网络。进一步凝练出江西省慢性病医防融合的4条实施路径：治理体系协同化、一体化管理精细化、中医药赋能多元化、医共体联动高效化。

江西省在推进医防融合慢性病管理方面已初步形成可复制、可推广的多元模式，但仍面临政策供需不平衡、跨部门协作不畅、人才保障不足及患者自我管理意识薄弱等问题。未来应从完善顶层设计、强化政策协同、优化医防一体化机制、发挥中医药优势和信息化支撑等方面着手，促进慢性病管理体系高质量发展，助力实现江西卫生健康现代化目标。