Abstract:During the period of the 12th Five-Year Plan, Chaoyang District in Beijing succeeded in being awarded with the title of the first national demonstration area of integrated prevention and control for chronic disease. The approach it conducted in the chronic disease management has achieved remarkable accomplishment and been praised by National Health and Family Planning Commission of People`s Republic of China. Based on the investigation and pectination of the management work done by various units in the district, the paper extracted the chronic disease care model in Chaoyang District from micro, meso, macro aspects according to ICCC(Innovative Care for Chronic Conditions) ,a globally popular chronic care theory. The paper summarized the features of the model and named it RIMM(Resident-Centered Integrated Management Model for Chronic Diseases): Under the positive policy environment, in two panels of prevention and management, with community health centers, residential committee and residents cooperating, resident-centered integrated management model for chronic diseases. Then, this paper analyzed the strengths and weaknesses of RIMM and put forward suggestions for optimizing the national chronic disease care system: all government sectors are supposed to be involved to maximize health outcomes; Community Healthcare Center need to play a more significant role in the management; the electronic information system ought to be improved; more chronic and more community resources should be put into the project.