深圳龙岗区正在构建覆盖"防、筛、管、治、康"全周期的慢性病管理体系，通过医防融合探索基层健康管理的新模式。1该区依托192家社康机构建设15分钟医疗服务圈，让符合条件的高血压、糖尿病及慢阻肺患者可就近获得每年不少于4次面对面随访和1次免费年度体检的管理服务。1
龙岗区整合家庭医生签约、健康科普、数字化管理和专科力量下沉等措施，将慢性病管理从医院延伸至社区和家庭。1截至2026年7月底，"龙岗家医"小程序注册用户超过74万人。1龙西社康管理的高血压患者超过2300名，糖尿病患者超过1200名。1龙岗推行"1+4"四师共管模式，由全科医师、公卫医师、全科护师和营养指导师协同开展患者管理。1在筛查端，社康普及免散瞳AI眼底相机技术，已筛查转诊超一万人次。1
2024年，广东省糖尿病一体化管理中心（深圳龙岗）落户龙岗区第四人民医院，进一步推动专科力量与基层服务的深度融合。1龙西社康等机构的管理经验已被省内外推广借鉴。1
Shenzhen's Longgang District has established a comprehensive chronic disease management system spanning prevention, screening, management, treatment, and rehabilitation, charting a new course for integrating medical care and disease prevention at the grassroots level 1. The district leverages 192 community health centers to create a 15-minute medical service radius, enabling residents to access quality care within walking distance 1.
Eligible residents with hypertension, diabetes, or chronic obstructive pulmonary disease can receive at least four in-person follow-up visits annually and one free annual health examination at nearby community facilities 1. The district implements a "1+4" co-management model comprising general practitioners, public health physicians, community nurses, and nutritional counselors to coordinate patient care 1. As of July 2026, the "Longgang Family Doctor" mini-program has registered over 740,000 users, expanding access to digital health management 1. Longxi Community Health Center alone manages over 2,300 hypertension patients and more than 1,200 diabetes patients 1.
Prevention and early detection capabilities have been strengthened through the widespread deployment of non-mydriatic artificial intelligence fundus cameras in community centers, which have conducted screening and referrals for over 10,000 patient visits 1. In 2024, the Guangdong Province Integrated Diabetes Management Center (Shenzhen Longgang) was established at Longgang District Fourth People's Hospital, consolidating the district's capacity for chronic disease management 1. Management practices from Longxi Community Health Center and other institutions have been promoted and adopted across the province and beyond 1.
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