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.

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结论要进一步在全科医疗实践中探索老年社区卫生服务模式。

Conclusions we suggest that we'd better explore the new community service model for Senior Citizens in General Medical Care research.

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