Chronic non-communicable diseases have become the primary factor threatening human health at present. The strategy of "Healthy China 2030" in 2016 emphasized the comprehensive prevention and control of chronic diseases for the first time. In recent years, a growing number of general practitioners in China have been playing an important role as gatekeepers of health in community health care and chronic disease management. Primary care managers (PCMs) selected from experienced senior nurses who have received an appropriate training can form health management teams with general practitioners to improve clinical efficiency and management outcomes in chronic disease populations according to domestic and international literature.

To explore the feasibility and sustainability of collaborative outpatient chronic disease management model based on medical team consisting of general practitioners, internists and PCMs in secondary private general hospital.

General practitioners or internists were assigned as primary care physicians (PCPs) for patients with essential hypertension and/or type 2 diabetes mellitus (T2DM) , physician assistants or senior nurses in the corresponding departments were trained as PCMs, PCPs and PCMs form chronic disease management teams to collaborate on the health management of patients with chronic diseases. The control of blood pressure and/or glycated hemoglobin in the dynamic and fixed populations of patients from April 2020 to August 2021 was reviewed, two indexes for the quality control including the rates of poorly controlled blood pressure and blood glucose were used to assess the effectiveness of chronic disease management collaboratively conducted by the PCP-PCM team. A questionnaire was used to obtain feedback from PCP-PCM team members on chronic disease management efforts, and a net promoter score (NPS) questionnaire was used for the investigation of patients satisfaction on PCP.

From April 2020 to August 2021, the rate of poorly controlled blood pressure in our hospital ranged from 18.34% to 20.82%, basically meeting the quality control target of no more than 20%; the rate of poorly controlled blood glucose ranged from 14.92% to 24.31%, with significant fluctuations, and did not meet the quality control target of no more than 20% in some months. The overall feedback from PCP-PCM team members on this chronic disease management model was very positive, but PCMs shared the concerns of excessive work load. The average NPS score for PCPs calculated from the results of 170 NPS questionnaires was 91, which was higher than than the average NPS department scores of general practitioners and internists in the same period (86 and 80, respectively) .

The chronic disease management model based on PCP-PCM team is effective in the improvement of clinical indicators in the hypertensive and diabetic patient populations, with positive feedbacks from PCPs, PCMs and patients suggesting feasibility of the chronic disease management model. However, the shortage of PCMs may have negative impact to the effectiveness of chronic disease management in long term, which is worthwhile to continue exploring in the sustainability of the model.

慢性非传染性疾病已成为当前危害人类健康的首要因素。2016年《"健康中国2030"规划纲要》首次提出对慢性病进行综合防控。近年来，国内的全科医生队伍越来越壮大，在社区居民的医疗保健和慢性病管理中发挥着重要的健康"守门人"作用。国内外文献报道，培训有经验的高年资护士成为健康经理（PCM），与全科医生组成健康管理团队，有助于提高工作效率，改善慢性病人群的管理效果。

探索民营二级综合医院全科医生、内科医师与PCM组成的医护团队合作开展门诊慢性病管理模式的可行性和可持续性。

安排全科医生或内科医师作为原发性高血压和/或2型糖尿病患者的初级保健医生（PCP），培训相应科室的医生助理或高年资护士作为PCM，PCP和PCM组成慢性病管理团队合作开展慢性病患者的健康管理工作。回顾2020年4月—2021年8月北京和睦家医院动态患者人群和固定患者人群的血压和/或糖化血红蛋白的控制情况，使用两个质控指标——血压控制不佳率和血糖控制不佳率，评估PCP-PCM团队合作开展的慢性病管理效果。使用调查问卷获取PCP-PCM团队成员对慢性病管理工作的反馈。使用净推荐值（NPS）问卷进行患者对PCP的满意度调查。

2020年4月—2021年8月，北京和睦家医院血压控制不佳率为18.34%~20.82%，基本达到不超过20%的质控目标；血糖控制不佳率为14.92%~24.31%，波动比较大，部分月份的血糖控制不佳率未达到不超过20%的质控目标。PCP-PCM团队成员对该慢性病管理模式的总体反馈非常积极，但PCM反馈工作量较大。由170份NPS问卷结果计算出PCP的NPS平均分高达91分，高于同期全科医生和内科医师的NPS科室平均分（分别是86分和80分）。

基于PCP-PCM团队合作的慢性病管理模式，在改善高血压和糖尿病患者人群的临床指标方面效果较好，并得到了PCP、PCM和患者三方的积极反馈，具有一定的可行性。但长远看，PCM的人员短缺问题或影响慢性病管理效果，值得在该模式的可持续性发展方面继续探索。