本文以北京市丰台区方庄社区卫生服务中心组建的家庭医生服务团队在社区糖尿病综合管理中的作用为例,介绍了家庭医生服务团队的建设、服务模式及内容,以社区糖尿病患者签约率、血糖控制率、规范健康管理率、患者就医行为变化情况等评价该服务模式效果,初步探索和总结了一种适合城市社区2型糖尿病患者综合管理的服务模式,为社区慢性病管理与防治提供借鉴。 This paper takes the role of family doctor service team established by Fangzhuang Community Health Service Center in Fengtai District of Beijing as an example in the integrated management of community diabetes. The article introduces the construction, service mode and content of family doctor service team, Blood glucose control rate, standardized health management rate, changes in patient medical behavior evaluation of the service mode effects, initially explored and summarized a suitable for urban community type 2 diabetes integrated management service model for community chronic disease management and prevention provide a reference.