针对目前我国农村、乡镇慢病发病率高但慢病诊疗与护理服务相对落后等问题,构建"以县级医院为核心-县级CDC为技术支撑-乡镇医院与社区为基础-家庭为延伸"的一体化慢病管理模式,并建立绩效考核激励机制保障该模式服务质量,最后从慢病远程护理及养老服务与慢病管理相结合两个视角展望后续研究工作.利用心理护理、社区护理、家庭护理与自我护理等护理模式实现医疗资源互联共享、参与各方优势互补、降低医疗费用、减轻疾病负担、改善医患关系,促进老龄社会和谐发展.%Based on the controversy of high incidence of noninfectious chronic diseases (NCD) in rural areas in China and relatively backwardness of NCD diagnosis, treatment and nursing services, an integrated chronic disease management model is constructed with "county level hospitals as core, county level CDC as technique support, township hospitals and communities as basis, and families as extension". The service quality of the model guaranteed by setting up an incentive mechanism of performance assessment. At last, follow-up research is forecasted from two perspectives of combination of long-distance nursing of NCD and services for the aged with NCD management. By utilizing nursing modes like psychological care, community care, family care, and self-care, etc., medical resources can be connected and shared, advantages of all parties involved complemented, medical costs lowered, disease burden relieved, doctor-patient relationship improved, and harmonious development of the aging society promoted.
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