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慢病健康管理服务的主战场在基层。本文回顾经典慢病健康管理研究证据，论证慢病健康管理的必要性和可行性，为实施慢病健康管理提供有力支撑和依据。同时，以深化医改新形势下国家层面组织开展的成功案例和健康管理领域慢病健康管理相关研究与实践为着重点，整理提炼具有基层实用性和推广性的实战经验，为慢病健康管理服务提供借鉴和指导。
<<The grassroots level is the main battle field of chronic disease health management. This report looked back on the research evidences on classic chronic disease health management，which provided the powerful support and demonstrated the necessity and feasibility of chronic disease health management. Meanwhile，on the basis of the successful cases and modes organized at the national level under the new situation of medical reform and the research and practice related to chronic disease health management in the field of health management，the report organized and refined practical and popularized experiences for the service of chronic disease health management at the grassroots level.
<<| Keywords： | Risk AssessmentCaseHealth InterventionEvidence-based MedicineChronic Disease Health Management |
