关键词: 糖尿病, 慢性病, 疾病管理, 瓦格纳慢性病服务模型, 澳大利亚, 中国

Abstract: It is a critical component of the development of the modern health care system to efficiently manage chronic diseases.The Wagner Chronic Care Model（CCM）widely used internationally provides a strong theoretical basis and practical framework for guiding chronic disease services.Australia has developed a more mature and effective management of chronic diseases under its universal health insurance system（Medicare），while China's chronic disease management is still at a stage of continuous exploration and innovation.We analysed the specific connotation of the six elements of Wagner CCM used in diabetes management.Then，based on the relevant experience of Australia using the model in diabetes management，we put forward practical suggestions to improve and promote the quality and results of diabetes management in China aiming at domestic current situation（including problems） of chronic disease management represented by diabetes.

Key words: Diabetes mellitus, Chronic disease, Disease management, Wagner Chronic Care Model, Australia, China