Core Insights - The National Health Commission has released guidelines to enhance chronic disease management services at the grassroots level, promoting a "one-stop" integrated service model for chronic disease management [1] - The initiative aims to provide comprehensive services including prevention, diagnosis, health management, referral, and information flow for chronic disease patients [1] Group 1: Implementation and Services - In Liaoning, community health service centers have begun to implement a "one-stop" chronic disease management area, offering full-service from screening to follow-up for residents [3][5] - The management of chronic diseases has evolved from "regular follow-ups" to "real-time monitoring, timely warnings, and proactive interventions" [7] - A total of 14,000 "1+N" family doctor service teams have been established in Liaoning to provide personalized service packages for chronic disease patients [7] Group 2: Regional Strategies - In Fujian, the guidelines suggest that township hospitals and community health service centers establish well-defined zones for chronic disease management, facilitating smooth patient flow [8] - The management approach in Fujian includes "grading, categorizing, marking, and segmenting" chronic disease patients based on their conditions and locations, aiming for localized care [8] - In Youxi County, patients are classified into red, yellow, and green categories based on their health status, with different levels of care provided accordingly [9] Group 3: Family Doctor Services - In Longyan City, family doctor services are being utilized to reduce hospital visits for chronic disease patients, providing continuous health guidance [13] - The signing rate of family doctors among key populations in Longyan County has reached 98.7%, significantly reducing the incidence of complications for hypertension and diabetes patients [15] - The shift from passive disease management to proactive prevention is becoming a reality, with the goal of keeping minor illnesses within villages and ensuring chronic diseases are managed effectively [15]