Objective To construct an intelligent health follow-up management system based on the Chronic Care Model, and to eva-luate its application effect in patients with chronic kidney disease.Methods A total of 172 patients with chronic kidney disease discharged from the renal department of a tertiary hospital in Zhejiang province were selected.According to the discharge time, the patients were divided into control group and observation group with 86 cases each.The control group was followed up as usual, while the observation group was followed up through the establishment of a intelligent health follow-up management system by forming a team, building a system architecture, establishing a special disease database, and developing application modules.After 6 months of intervention, the differences in self-management ability, estimated glomerular filtration rate (eGFR), blood creatinine, urine microalbumin creatinine ratio (ACR), systolic blood pressure, diastolic blood pressure and BMI were compared between the two groups.Results There were 84 cases in the control group and 85 cases in the observation group completed the study.After 6 months of intervention, the self-management ability score of the observation group was significantly higher than that of the control group, and the values of creatinine, ACR, systolic blood pressure, diastolic blood pressure, and BMI were significantly lower than those of the control group (all P＜0.05); there was no statistically significant difference between the eGFR of the two groups before and after the intervention (P＞0.05).Conclusion Intelligent health follow-up management system based on chronic disease management model can improve the self-management ability in patients with chronic kidney disease and delay the progression of chronic kidney disease.