【摘要】 聚焦慢性病管理“全周期、连续性、协同性”理念，探索实施“目标—分工—支撑—创新”四维联动的“县医院—乡镇卫生院—村卫生室”三级协同慢性病管理模式，通过明确分工、药品“五统一”管理、搭建信息平台、建立激励机制等基础建设，以及转诊“绿色通道”、家庭医生“1+1+1+”模式、“县医返村”等机制深化，形成慢性病闭环管理体系，提升了慢性病管理能力，为同类地区提供了路径参考。更多还原

【Abstract】 Focusing on the concepts of "full-cycle,continuity,and collaboration" in chronic disease management,this study explores the implementation of a three-tier collaborative chronic disease management model involving "county-level hospitals,township health centers,and village clinics" through a four-dimensional linkage approach of "objectives-division of labor-support-innovation".By establishing foundational measures such as clarifying division of labor,implementing "five unifications" in pharmaceutical management,constructing an information platform,and establishing incentive mechanisms,along with innovative mechanisms including a referral "green channel",the " 1+1+1+" family doctor model,and the "county doctors returning to villages" initiative,a closed-loop management system for chronic diseases has been formed.This approach has enhanced chronic disease management capabilities and provided a path reference for similar regions.更多还原