The increase in chronic diseases resulting from an aging population and changes in lifestyle poses health threats at the individual level and leads to an increased burden of medical expenses at the societal level. In particular, hypertension and diabetes are representative chronic diseases, requiring a systematic support system for continuous disease management.

In this lecture, a primary care chronic disease program was introduced, which provides comprehensive and continuous health management for hypertension and diabetes patients at local clinics, and health support services designed to enhance self-management capabilities for these patients were presented.