中文摘要：

目的评价慢性病保健模型在社区高血压管理中应用的效果。方法采用实验对照研究方法，在杭州市朝晖社区选取高血压患者300名，分为实验组和对照组。实验组按照慢性病保健模型设计干预措施，对照组仍按社区原有方法管理，9个月后比较两组患者干预前后相关指标变化。结果干预前后，实验组在饮酒习惯、每日用盐量（降低0．78g）、舒张压（降低2mmHg）、体质指数（降低0．4）和SF-36生理得分（降低1．7）上有改善（P〈0．05），实验组在体重指数和SF-36生理总分上的变化值高于对照组。结论慢性病保健模型通过对患者饮食、运动及其他健康相关危险因素的引导干预达到提高健康产出的目的，对我国的社区高血压管理有一定借鉴意义。

英文摘要：

Objective To evaluate the effectiveness of Chronic Care Model in hypertension managnentin community health services. Methods Three hundred patients diagnosed with hypertension participated in this study and were divided into intervention and control groups In the following 9 months, intervention measures based on the Chronic Care Model were delivered to intervention group, while the conventional measures to control group. Data collected before and after the intervention were analyzed using descriptive statistics, t-test, 3（2-test and analysis of covariance by SPSS 16. 0 for Windows. Results The intervention group bad statistically significant positive effectiveness in drinking habit, daily salt intake（decreased 0. 78g）, diastolic blood pressure （decreased 2mmHg）, BMI （decreased 0. 4） and SF-36 physical component summary score （decreased 1.7） （P〈0. 05）. The intervention group bad better improvement in BMI and SF-36 physical component summary score than the control group. Conclusion The health outcomes of patients with hypertension could be improved by applying the Chronic Care Model featured diet, exercise habits and other health related factors management.