探索用社区导向基层医疗（COPC）模式，对社区高血压病、糖尿病患者进行系统管理的效果。
To explore the effect of systematic management of hypertension and diabetes with community oriented primary care (COPC) model.
医务人员必须加大医患之间的交流与合作，培养病人提高自我管理意识，采取有效的措施共同控制高血压病。
The medical workers should strengthen the communication between doctors and patients, train patients to increase self-management awareness, and take effective measures to control hypertension.
结论以糖尿病、高血压病为代表的慢性病患者综合管理效果显著。
Conclusions The comprehensive management for diabetes, hypertension, and such chronic diseases was effective.
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