2012年,杨叔禹走马上任福建省厦门市卫生局局长岗位,上任之始,他便带领团队开始探索“糖尿病医院社区一体化全程关照计划”。两年多来,在他带领下,厦门市不断探索慢病分级管理的有效途径,创建了“糖尿病病友全程关照网”(简称糖友网),2015年,“高血压病友全程关照网”(简称高友网)也正式挂牌启动了。厦门市通过创设大医院专科医师、基层医疗卫生机构全科医师和健康管理师“三师共管”服务模式, In 2012, Yang Shuyu took the post of director of the Xiamen Municipal Health Bureau in Fujian Province. After taking office, he led the team to start exploring “the plan for the whole integration of diabetes hospital community.” Over the past two years, under his leadership, Xiamen City has been exploring an effective way of grading management of chronic diseases and creating a “Care Network for Diabetic Patients” (referred to as “Sugar Friends Network” for short). In 2015, “Hypertensive patients with full care Network ”(referred to as high Friends Network) has also officially started. Xiamen City, through the creation of a large hospital specialist, primary health care practitioners and general practitioners, health management division, “three co-management” service model,