随着我国疾病谱和死亡谱的变化,以及人口老龄化和生活行为方式的改变,慢性非传染性疾病(慢性病,NCD)迅速上升,已成为我国主要的公共卫生问题。慢性病受累人多、致残率高、医疗费用昂贵,是沉重的社会负担。为了在乡镇中做好慢性病病人的动态健康管理,切实改善老年人的身心健康,? With the change of disease spectrum and death spectrum in our country, as well as the change of population aging and living behavior, chronic non-communicable diseases (chronic diseases, NCD) increase rapidly and become the major public health problems in our country. Many people suffer from chronic diseases, high rates of disability and high medical costs are a heavy social burden. In order to do a good job of dynamic health management of patients with chronic diseases in villages and towns and earnestly improve the physical and mental health of the elderly,