Abstract:The establishment of a hierarchical diagnosis and treatment system is an important measure to rationally allocate medical resources and promote the equalization of basic medical and health services. From the perspective of the arduous task of chronic disease management，the current situation of chronic disease management in Changshu City and the existing problems in the construction of hierarchical diagnosis and treatment system，this paper analyzes that the root cause of the problem of “easy transfer from top to bottom” lies in the integration of clinical pathway and diagnosis and treatment standards in the process of referral. In addition，the clinical integration strategy is not clear，the drug catalog is not unified，and the information linkage is not smooth. The specific methods for the construction of the hierarchical diagnosis and treatment system for chronic diseases were put forward，including resource integration and medical community construction，expanding clinical pathways，establish a team of "specialists + general practitioners" to enhance the driving force of referral，information support，prescription flow to help chronic disease system and other measures.The preliminary results and experience were summarized. Under the model of the county medical community，a tertierychronic disease prevention and treatment system of city，town and village with guidance and support at the city level，management at the town level，and screening at the village level was established to form a scientific and reasonable medical order，with the hierarchical diagnosis and treatment of chronic diseases as a breakthrough.