72岁的居民史宝权在社区"呼吸慢病数智诊疗中心"接受肺功能检测，检测数据实时传输至医生管理终端。 居民 史宝权：我是重度慢阻肺，以前就得上大医院，现在社区医院离得挺近，服务态度也好，还能免费测肺功能、拿药，都一步搞定了，很方便。 今年11月，该社区卫生服务中心将呼吸慢病原先分散的管理环节整合衔接，形成了连续、闭环的健康服务链。 近日，国家卫生健康委发布《基层慢性病健康管理服务能力建设指引》，指导各地根据需要促进基层慢性病健康管理服务能力建设，提供"一站式"功能 整合的基层慢性病健康管理服务。 《基层慢性病健康管理服务能力建设指引》包括：对辖区居民开展慢性病预防、诊疗、健康管理服务以及转诊、信息汇总流转等核心功能；合理划分健 康服务区与诊疗区，做到功能分区明确、导向标识清晰、人员动线流畅；配备全科医生、中医医师、公共卫生医生、药师、护士等卫生专业技术人员；根据 慢性病健康管理服务的需要配备相关设施设备；加强数智化应用，推进实现诊疗、体检、基本公共卫生服务等方面信息数据交汇共享。 筛查、诊断、治疗、随访等家门口"一站式"解决 据了解，此前已经有部分地区尝试类似探索，为居民提供基层慢性病管理服务。这一服务是如何开展 ...

Core Viewpoint - The National Health Commission of China has released guidelines to enhance chronic disease health management services at the grassroots level, aiming to provide systematic, continuous, and high-quality services for chronic disease patients in urban and rural communities [1][2] Group 1: Implementation Timeline - By 2027, counties (cities, districts) with integrated medical communities are expected to achieve full-process chronic disease health management services, with increased utilization by chronic disease patients [1] - By 2030, a systematic and continuous service model for chronic diseases is to be widely applied at the grassroots level, further expanding the population benefiting from these services [1] Group 2: Service Integration - The guidelines emphasize the integration of chronic disease health management services, focusing on the roles of four types of institutions: township health centers, community health service centers, village clinics (community health service stations), and leading hospitals within integrated medical communities [1] - The role of public health institutions, such as disease prevention and control centers, is highlighted for providing technical guidance [1] Group 3: Service Focus Areas - The guidelines outline five key areas for improving chronic disease health management: risk assessment and services, classified and graded health management, multi-disease management, traditional Chinese medicine health services, and self-health management for patients [2]