许多研究指出,大多数高血压患者的血压控制效果欠佳,分析其原因,主要是患者对疾病的认识欠充分、长期规范化治疗的依从性不足[1-3]。近年来,许多地方开始将家庭医生责任制应用到高血压患者的管理中,相较于以往的社区管理模式,家庭医生责任制取得了更好的效果[4]。在肯定家庭医生制度对高血压患者管理积极意义的同时,家庭医生团队如何更好地对高血压患者进行管理成为一个有待探索研究的新问题。笔者所在团队通过近3年的实践探索,总结出一套家庭 Many studies have pointed out that the majority of patients with hypertension control of blood pressure is not good, the analysis of the reasons, mainly due to lack of awareness of the disease in patients with long-term standardized treatment of inadequate compliance [1-3]. In recent years, many places have started to apply the family doctor’s responsibility system to the management of hypertensive patients. Compared with the previous community management mode, the family doctor’s responsibility system has achieved better results [4]. While affirming the positive effect of the family doctor system on the management of hypertensive patients, how the family doctor team can better manage the hypertensive patients becomes a new problem to be explored and studied. The author’s team through nearly three years of practical exploration, summed up a family