【摘要】 社区慢性病管理模式在中国慢性病管理实践中发挥了巨大作用，但随着数字健康时代的到来，“被动管理”向“主动管理”转变势必成为新趋势。该文分析了以社区慢性病管理模式为主的传统慢性病管理模式，进一步提出了一种新型的慢性病管理模式——基于主动健康指数的慢性病精准管理模式，并明确了构建该模式的技术路径，为提升居民健康管理主动性，加强慢性病管理提供了一种新的解决方案。更多还原

【Abstract】 The community health management model of chronic disease has played a great role in the practice of chronic disease management in China,but with the advent of the digital health era,the transformation of "passive management" to "proactive management" is bound to become a new trend. The paper analyzed the traditional chronic disease management model,and put forward a new chronic disease management model named "Precise Health Management Model based on proactive health index" and the technical logic of the model construction was defined for promoting the activity of resident health management. It provided a new solution scheme to strengthen the health management of chronic diseases.更多还原