慢性病保健模型在糖尿病长期管理中的应用研究

慢性病具有病程长、发病率高、致残和致死率高等特点，慢性病的一体化管理是各国普遍关注的问题。慢性病保健模型（CCM）是针对慢性病长期管理搭建的系统框架，目前已得到广泛应用和认可。本文介绍了CCM的内容，包括医疗系统或机构、临床信息系统、决策支持、服务提供系统、自我管理支持、社区资源与政策6个元素，同时介绍了CCM在不同级别医疗机构糖尿病管理中的应用效果，并在此基础上提出了对我国实施CCM的建议，以期为我国基层医疗机构的糖尿病长期管理提供参考。

Chronic Care Model in Long-term Management of Diabetes

Chronic diseases have the characteristics of long duration，high incidence rate，high disability rate and high fatality rate，so the integrated management of chronic diseases is commonly concerned by the world.The chronic care model（CCM） is a system that has been widely used and recognized for long-term management of chronic diseases.This paper introduces CCM with its medical system/institutions，clinical information system，decision support system，service delivery system，self-management support system，and community resources and policies.At the same time，this paper describes the application of CCM in long-term management of diabetes at different levels of medical institutions and puts forward suggestions for the implementation of CCM in China in order to provide reference for the long-term management of diabetes in primary healthcare institutions in China.