Chronic non-communicable diseases have become the primary factor threatening human health at present. The strategy of "Healthy China 2030" in 2016 emphasized the comprehensive prevention and control of chronic diseases for the first time. In recent years, a growing number of general practitioners in China have been playing an important role as gatekeepers of health in community health care and chronic disease management. Primary care managers (PCMs) selected from experienced senior nurses who have received an appropriate training can form health management teams with general practitioners to improve clinical efficiency and management outcomes in chronic disease populations according to domestic and international literature.

To explore the feasibility and sustainability of collaborative outpatient chronic disease management model based on medical team consisting of general practitioners, internists and PCMs in secondary private general hospital.

General practitioners or internists were assigned as primary care physicians (PCPs) for patients with essential hypertension and/or type 2 diabetes mellitus (T2DM) , physician assistants or senior nurses in the corresponding departments were trained as PCMs, PCPs and PCMs form chronic disease management teams to collaborate on the health management of patients with chronic diseases. The control of blood pressure and/or glycated hemoglobin in the dynamic and fixed populations of patients from April 2020 to August 2021 was reviewed, two indexes for the quality control including the rates of poorly controlled blood pressure and blood glucose were used to assess the effectiveness of chronic disease management collaboratively conducted by the PCP-PCM team. A questionnaire was used to obtain feedback from PCP-PCM team members on chronic disease management efforts, and a net promoter score (NPS) questionnaire was used for the investigation of patients satisfaction on PCP.

From April 2020 to August 2021, the rate of poorly controlled blood pressure in our hospital ranged from 18.34% to 20.82%, basically meeting the quality control target of no more than 20%; the rate of poorly controlled blood glucose ranged from 14.92% to 24.31%, with significant fluctuations, and did not meet the quality control target of no more than 20% in some months. The overall feedback from PCP-PCM team members on this chronic disease management model was very positive, but PCMs shared the concerns of excessive work load. The average NPS score for PCPs calculated from the results of 170 NPS questionnaires was 91, which was higher than than the average NPS department scores of general practitioners and internists in the same period (86 and 80, respectively) .

The chronic disease management model based on PCP-PCM team is effective in the improvement of clinical indicators in the hypertensive and diabetic patient populations, with positive feedbacks from PCPs, PCMs and patients suggesting feasibility of the chronic disease management model. However, the shortage of PCMs may have negative impact to the effectiveness of chronic disease management in long term, which is worthwhile to continue exploring in the sustainability of the model.