Abstract: In China，the aggravated population aging has boosted the demands of the elderly for health，medical and nursing services，and the popularization of the internet and smart tech products is increasing.To promote the development of elderly and medical care industries to satisfy the health needs of older people，integrating the internet technologies into integrated medical and nursing care and community-based care，is a good way yet a big problem that needs to be discussed and solved urgently.In this paper，we discussed the implementation of internet-based integrated medical and nursing for health management of community-dwelling elderly people with chronic diseases，and analyzed the opportunities and challenges during the implementation.Moreover，corresponding countermeasures were put forward as follows：further increasing the government support，improving the offline service capabilities and realizing a closed loop management with the integrated medical and nursing care，training high-quality professional care providers，strengthening the supporting role of information technology，building an age-friendly society，integrating resources by attracting more companies engaged in elderly care industry and more investments into the industry，and developing an internet-based elderly care pattern suitable for domestic conditions with joint efforts of multidisciplinary teams. In addition，in an explorative way，we developed a comprehensive health management system of internet-based integrated medical and nursing，which includes the basic database subsystem，end-user subsystem，service subsystem，and supervision and evaluation subsystem.

Key words: Internet+, Combination of medical care and pension, Aged, Chronic disease, Countermeasure

摘要： 随着我国人口老龄化进程的加剧，老年人对医疗服务、养老服务及健康的需求也逐渐加大。随着我国互联网以及智能化产品的普及，如何将医养结合社区养老模式与互联网有机融合，推进养老和医疗服务的快速发展也成为目前亟须探讨并解决的一大问题。本文探讨了我国“互联网+医养结合”在社区老年慢性病人群健康管理中的发展现状，分析面临的机遇和挑战，并提出相应的对策。针对我国“互联网+医养结合”养老模式的现状和存在的困难，提出了应对策略，包括：继续加大政府支持力度；提高线下服务能力，实现医养结合服务的闭环；培养优秀人才；强化信息技术支持作用，建设老年友好社会；整合资源，吸引更多企业和资本进入养老行业，共同探讨和创造适合我国国情的养老服务模式。在此基础上，本文尝试构建了包含基础数据库系统、终端用户系统、服务系统、监督与评价系统等在内的全面的“互联网+医养结合”健康管理服务体系。

关键词: 互联网+, 医养结合, 老年人, 慢性病, 对策