高血压病管理是上海社区医院慢性病管理的重点工作,也是预防和控制人群冠心病、脑卒中高发病、高死亡的主要手段之一[1]。但是由于高血压发病人数的逐年递增,管理工作量的不断增加,社区医务人员人力资源缺乏等原因,如仅局限于原来医生参与的高血压分层分组管理模式已不能满足患 Hypertension management is the focus of chronic disease management in Shanghai Community Hospital and one of the main measures to prevent and control coronary heart disease, high incidence of stroke and high death [1]. However, due to the increasing number of hypertensive patients, the increasing management workload and the lack of human resources in community medical personnel, the stratified group management mode of hypertension that is limited to the original doctors can no longer meet the needs of patients