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目的：探讨基于整合模式的社区慢性病患者健康管理的效果。方法2014年4月至2015年6月，将北京市德胜社区全科门诊的签约慢性病患者按健康档案号排序后，每隔5例抽取1例，总共抽取834例作为研究对象，再按健康档案单双号随便分为两组，干预组423例，对照组411例。干预组采用整合模式进行健康管理，对照组采用一般社区慢性病健康管理方法。采用自制的调查问卷进行两组患者知识、态度、行为生活方式的测量。采用卡方检验比较管理前后两组患者各项指标的变化。结果通过1年的整合模式的健康管理，干预组在慢性病知识如诊断依据（84.9%）、危险因素（88.0%）、正确服药方法（95.2%）、预防慢性病的生活方式（89.6%）、定期体检（96.9%）等方面达标率均高于对照组（56.3%、53.6%、59.5%、55.8%、62.7%，?2=81.270、118.394、155.166、119.672、150.173，P<0.05）；干预组在慢性病的防治态度如对所患慢性病的重视程度（80.8%）、对家庭医生式服务（78.2%）及护士健康管理（81.8%）的认可程度、对改变危险因素的态度（77.5%）等方面达标率均高于对照组（59.0%、54.3%、52.8%、56.5%，?2=46.573、52.429、78.435、40.744，P<0.05）；干预组在行为生活方式改善率方面，如饮食（76.7%）、运动（72.2%）、心理状态（90.6%）及遵医行为中的正确服药（99.3%）、监测血压（86.1%）、监测血糖（42.0%）均显著高于对照组（30.9%、30.6%、58.0%、73.1%、57.5%、28.9%，?2=174.142、142.147、115.318、119.783、83.164、15.341，P<0.05）；干预组血压控制率（84.2%）、血糖控制率（74.8%），均高于对照组（74.3%、60.0%，?2=11.598、20.576，P<0.05）。结论基于整合模式的健康管理在社区慢性病综合干预中是一种有效的方法，有利于提高慢性病的管理效果。

Objective To explore the effectiveness of KAP-HBM-TTM(KHT)-based health management on patients with chronic diseases in community. Method From April 2014 to June 2015, 834 patients with chronic diseases living in Desheng Community were randomly sampled and assigned to the intervention group (n=423, and the control group n=411). The K-H-T mode was used for the intervention group, and the routine management mode was applied to the control group. Using self-made questionnaire we tested two groups of patients' knowledge, attitude and life-style behavior. Chi-square test was used for data analysis. Result After one year KHT-based health management, the proportion of patients with reaching the standard knowledge such as diagnosis based, risk factors, correct treatment method, life-style for prevention of chronic disease and regular check-up of the intervention group (84.9%, 88.0%, 95.2%, 89.6%, 96.9%) obviously raised compared with the control group (56.3%, 53.6%, 59.5%,55.8%, 62.7%), and the difference was statistically significant (? 2=81.270, 118.394, 155.166, 119.672, 150.173,P<0.05). The proportion of patients with reaching the standard attitude such as on the importance of chronic diseases, the family doctor service, the nurses' health management and changing risk factors of the intervention group (80.8%, 78.2%, 81.8%, 77.5%) obviously raised comapred with the control group (59.0%, 54.3%, 52.8%, 56.5%), and the difference was statistically significant (?2=46.573, 52.429, 78.435, 40.744,P<0.05). The proportion of patients with reaching the standard life-style behavior such as diet, physical exercises, psychological states, correct medication, monitoring blood pressure and glucose of the intervention group (76.7%, 72.2%, 90.6%, 99.3%, 86.1%,42.0%) obviously raised than the control group (30.9%, 30.6%, 58.0%, 73.1%, 57.5%, 28.9%), and the difference was statistically significant (? 2=174.142, 142.147, 115.318, 119.783, 83.164, 15.341,P<0.05). The rate of blood pressure and glucose control of the intervention group (84.2%, 74.8%) also improved as compared with the control group (74.3%, 60.0%), and the difference was statistically significant (? 2=11.598, 20.576,P<0.05). Conclusion KAP-HBM-TTM (KHT)-based health management was proved to be effective in the control of chronic diseases of community and improve the effectiveness of the management.