Abstract： Objective To explore the effectiveness of KAP-HBM-TTM(KHT)-based health management on patients with chronic diseases in community. Method From April 2014 to June 2015, 834 patients with chronic diseases living in Desheng Community were randomly sampled and assigned to the intervention group (n=423, and the control group n=411). The K-H-T mode was used for the intervention group, and the routine management mode was applied to the control group. Using self-made questionnaire we tested two groups of patients' knowledge, attitude and life-style behavior. Chi-square test was used for data analysis. Result After one year KHT-based health management, the proportion of patients with reaching the standard knowledge such as diagnosis based, risk factors, correct treatment method, life-style for prevention of chronic disease and regular check-up of the intervention group (84.9%, 88.0%, 95.2%, 89.6%, 96.9%) obviously raised compared with the control group (56.3%, 53.6%, 59.5%,55.8%, 62.7%), and the difference was statistically significant (? 2=81.270, 118.394, 155.166, 119.672, 150.173,P<0.05). The proportion of patients with reaching the standard attitude such as on the importance of chronic diseases, the family doctor service, the nurses' health management and changing risk factors of the intervention group (80.8%, 78.2%, 81.8%, 77.5%) obviously raised comapred with the control group (59.0%, 54.3%, 52.8%, 56.5%), and the difference was statistically significant (?2=46.573, 52.429, 78.435, 40.744,P<0.05). The proportion of patients with reaching the standard life-style behavior such as diet, physical exercises, psychological states, correct medication, monitoring blood pressure and glucose of the intervention group (76.7%, 72.2%, 90.6%, 99.3%, 86.1%,42.0%) obviously raised than the control group (30.9%, 30.6%, 58.0%, 73.1%, 57.5%, 28.9%), and the difference was statistically significant (? 2=174.142, 142.147, 115.318, 119.783, 83.164, 15.341,P<0.05). The rate of blood pressure and glucose control of the intervention group (84.2%, 74.8%) also improved as compared with the control group (74.3%, 60.0%), and the difference was statistically significant (? 2=11.598, 20.576,P<0.05). Conclusion KAP-HBM-TTM (KHT)-based health management was proved to be effective in the control of chronic diseases of community and improve the effectiveness of the management.