With the development of society and the improvement of people's living standards, health issues are receiving increasing attention. The aging population and the high incidence of chronic diseases have made health management an urgent problem that needs to be addressed. Primary healthcare institutions, as the "main battlefield" for residents' health, play a crucial role in health management. However, in the current implementation of health management, primary healthcare institutions still face numerous challenges, and their proactivity remains unclear.

To understand the current implementation status of health management in primary healthcare institutions in Shanghai and to discuss strategies for enhancing the implementation of proactive health-oriented health management.

From February 2023 to May 2023, a survey was conducted on 33 primary healthcare institutions in Shanghai. The survey aimed to understand the implementation of health management, assessment of high-risk factors and disease screening, execution of health education and information dissemination, coordination of health management resources and functional services, as well as the status of online health management services and health monitoring. Additionally, interviews were conducted with institution heads to gather information on implementation difficulties and suggestions.

The research results showed that all participating institutions carried out health management for chronic disease patients, with 93.9% (31/33) covering key populations, 72.7% (24/33) involving rehabilitation populations, and 54.6% (18/33) including healthy populations. A total of 81.8% (27/33) of institutions utilized health data platforms, with the main functions including contract management, health record management, data querying, and health indicator management. Furthermore, 97.0% (32/33) of institutions conducted high-risk factor assessments and disease screenings, as well as follow-up, diagnosis, and management. The majority of institutions carried out health education and information dissemination activities through various platforms. Additionally, 87.9% (29/33) of institutions collaborated with other units to implement health management projects, providing diverse functional services. About 63.6% (21/33) of institutions offered online services, and 42.4% (14/33) were equipped with health monitoring devices. Managers believed that primary healthcare institutions and their staff have significant advantages in implementing proactive health-oriented management, but they also face challenges due to a lack of policy and financial support.

Primary healthcare institutions in Shanghai have made positive progress in implementing proactive health-oriented management. However, comprehensive measures are still needed to address existing challenges, in order to further improve the quality and efficiency of health management services and better meet the health needs of residents.

随着社会经济的发展和人民生活水平的提高，健康问题日益受到重视。人口老龄化和慢性病的高发率使得健康管理成为一个迫切需要解决的问题。基层医疗卫生机构作为居民健康的"主战场"，在健康管理方面发挥着重要作用。然而，当前基层医疗卫生机构在健康管理的实施过程中，仍然面临诸多挑战和主动性尚不明确的问题。

了解目前上海市基层医疗卫生机构健康管理的实施状况，讨论提升主动健康导向的健康管理的实施策略。

于2023年2—5月，通过对上海市33家基层医疗卫生机构调查，了解其健康管理的开展、对疾病高危因素的评估及疾病筛查、实施健康教育及信息传播、健康管理资源的协调及功能服务、健康管理线上服务及健康状况监测情况，并对机构负责人实施困难及建议访谈。

参与机构均开展针对慢性病人群的健康管理，93.9%（31/33）覆盖重点人群，72.7%（24/31）涉及康复人群，54.6%（18/31）包括健康人群。81.8%（27/33）的机构应用健康数据平台，主要功能包括签约管理、健康档案管理、数据查询和健康指标管理。97.0%（32/33）的机构开展疾病高危因素评估和筛查，以及随访、诊疗和管理。绝大多数机构通过多种平台开展健康教育和信息传播活动。87.9%（29/33）的机构与其他单位合作开展健康管理项目，提供多样化的功能服务。63.6%（21/33）的机构提供线上服务，42.4%（14/33）配备健康监测设备。管理者认为基层医疗卫生机构及基层医务人员在实施主动健康导向的健康管理方面有显著优势，但也面临缺乏政策和财政支持的困难。

上海市基层医疗卫生机构在实施主动健康导向的健康管理方面取得了积极进展，但仍需针对存在的挑战采取综合措施，以进一步提高健康管理服务质量和效率，更好地满足居民的健康需求。