军队干休所老干部已逐步进入“双高期”(高年龄、高发病期),大多患有心脑血管疾病(高血压病、冠心病、脑卒中)、糖尿病、恶性肿瘤、慢性阻塞性肺疾病(慢性气管炎、肺气肿)等多种慢性病[1-2]。慢性疾病管理是指在社区广泛使用系统化、结构化、多学科等多种方法,促进慢性疾病患者自我管理,并根据疾病严重程度、患者需要和目前相关证据,科学管理相关疾病,及 Military cadres have been gradually entering the “double high” (high age, high incidence), most suffering from cardiovascular and cerebrovascular diseases (hypertension, coronary heart disease, stroke), diabetes, cancer, chronic obstruction Sexual lung disease (chronic bronchitis, emphysema) and other chronic diseases [1-2]. Chronic disease management refers to the widespread use of systematic, structured and multidisciplinary approaches in community to promote self-management of patients with chronic diseases and to scientifically manage the disease according to the severity of the disease, patient needs and current evidence, and