ABSTRACT
From April to November 2019, 5 community health service centers in Shanghai Hongkou District were randomly selected for thematic group interviews to investigate the current status, problems and challenge for further development of chronic disease management. The community chronic disease management was mainly divided into growth period (typically hypertension and diabetes) and introduction period (cardiovascular and cerebrovascular diseases, respiratory diseases, dementia, osteoporosis). The management of hypertension and diabetes in the growing stage mainly faced difficulties such as refusal or non-cooperation of patients, loss of follow-up, incomplete quality control, not meeting quality control indicators, repeated management of comorbidities, insufficient information sharing, and discrepancy in assessment indicators of multiple parties. The management of cardiovascular and cerebrovascular diseases, respiratory diseases and other diseases in the introduction period mainly faced poor awareness rate of patients, loss of follow-up, difficulty in diagnosis, irregular medication, insufficient information sharing, lack of management plan, insufficient resource investment, and few variety of medicines in the community. The current management system should be refined to provide more effective and efficient chronic disease management in the community. Meanwhile, the awareness of residents, the information network and multi-center collaborative research also need to be strengthened.