Abstract: The distribution of medical resources in China is imbalanced nowadays. Most high-quality medical resources are distributed in tertiary hospitals，but not in primary healthcare institutions. Insufficient resources hinder primary healthcare institutions from playing their due role in promoting the development of the hierarchical medical system，to satisfy the health needs of residents. Therefore，the supply-side reform in pharmaceutical and healthcare fields is imperative. The "Healthy China 2030" Planning Outline put forward goals for realizing the innovation of the patterns of healthcare provision and achieving a mature and sound hierarchical medical system in an all-round way. The construction of a medical consortium is a way to promote the development of hierarchical medical system by integrating the local medical resources and allocating high-quality resources to primary care using a guided approach. We analyzed the structure of chronic disease management teams of medical consortium of Beijing Chao-Yang Hospital，Capital Medical University，consisting mainly of specialists from general hospitals，general practitioners and health managers from community healthcare institutions，detailed the teams' delivery process of contracted family doctor services，summarized the teams' features and positive role in promoting the development of hierarchical medical system，with a view to providing a reference for facilitating the full implementation of this system.

Key words: Medical health alliance, Hierarchical medical system, Chronic disease management, Specialist physicians-general practitioners combination

摘要： 目前，我国医疗资源分配不均衡，优质资源多集中于三级医院，导致分级诊疗难以落实到位，无法满足人民群众对健康的高要求，因此医药卫生领域的供给侧改革势在必行。《“健康中国2030”规划纲要》提出创新医疗卫生服务供给模式，全面建立成熟完善的分级诊疗制度。医联体模式可以通过整合内部医疗资源，引导优质资源下沉，进而实现分级诊疗的目标。本文以首都医科大学附属北京朝阳医院医联体的“专全结合”慢性病管理团队为例，介绍了团队内的综合医院专科医师、社区医院全科医生及健康管理师如何开展医联体特色的家庭医生式签约服务，并分析其特点和积极作用，为分级诊疗的全面实施提供参考。

关键词: 医联体, 分级诊疗, 慢性病管理, 专全结合