目的：基于紧密型医共体内整合健康管理服务模式，探究慢性病患者健康的影响因素。方法：基于某县全民健康体检数据、医疗服务记录库等进行样本筛选，采用整群抽样的方式，共调查糖尿病重点人群20 23人，分为干预组955人，对照组1 068人，对其开展基本情况及相关问卷调查。结果：两组患者的自我管理行为维度，干预组患者的总体得分（40.22±8.52）高于对照组患者的总体得分（35.76±6.49），干预组患者的总体自我管理水平更好，差异具有统计学意义（P < 0.05）；在患者的健康饮食、运动管理、血糖监测、足部护理四个维度中，两组糖尿病患者差异有显著的统计学意义（P < 0.05）。两组患者的生命质量维度，干预组糖尿病患者的生命质量得分（46.81±8.69）显著低于对照组（49.60±7.57）；在糖尿病患者中干预组在生理功能、心理精神、社会关系、治疗感受的得分都显著低于对照组，且差异有统计学意义（P < 0.05）。根据回归模型，糖尿病患者的自我管理行为受到糖尿病健康知识、糖尿病相关情绪状态、自我效能、社会支持、性别、个人年收入、情绪疾病以及自评健康的显著影响。同时糖尿病患者的生命质量受糖尿病相关情绪状态、自我效能、社会支持、年龄、性别、个人年收入、自我照护能力的显著影响。结论：在紧密型医共体背景下，整合健康管理能有效帮助慢性病患者提升自我管理健康水平，同时能明显提升慢性病患者的生活质量，帮助患者全方位提升自我健康水平。

Objective：To explore the factors affecting the health of patients with chronic diseases by the integrated health management service model of compact medical community. Methods：Samples were screened based on the national health examination data and medical service record database of a certain county. A total of 2，023 people with diabetes mellitus were investigated by cluster sampling，which were divided into 955 people in the intervention group and 1，068 people in the control group. The basic information and related questionnaires were carried out. Results：In terms of self-management behavior，the overall score of the intervention group was（40.22±8.52）and that of the control group was（35.76±6.49）. The overall self-management level of the intervention group was better，with statistical significance（P < 0.05）. There was significant statistical significance in the four dimensions of healthy diet，exercise management，blood glucose monitoring and foot care between the two groups of diabetes patients（P < 0.05）. Among the two groups of patients in terms of quality of life，，the quality of life score in the intervention group（46.81±8.69）was significantly lower than that in the control group（49.60±7.57）. In diabetic patients，the scores of physiological function，psychological spirit，social relationship and treatment experience in the intervention group were significantly lower than those in the control group，and there was statistical significance（P < 0.05）. According to the regression model，the self-management behavior of diabetic patients was significantly affected by diabetes health knowledge，diabetes-related emotional state，self-efficacy，social support，gender，personal annual income，emotional illness，and self-rated health. Meanwhile，the quality of life of diabetic patients was significantly affected by diabetes-related emotional state，self-efficacy，social support，age，gender，personal annual income and self-care ability. Conclusion：Under the background of compact medical community，integrated health management can effectively help patients with chronic diseases improve their self-management health level，and can significantly improve the quality of life of patients with chronic diseases，and help patients to comprehensively improve their self-health level