Chronic disease poses a great threat to people’s health in China. The chronic disease management is a key area of health work in China. With the development of healthcare reform, health awareness is becoming more and more important. One significant reason that associates with poor population is difficult to get rid of poverty in China is “falling into illness in poverty, staying in poverty due to illness”. For winning the tough battle against poverty, anti-poverty programs in health promotion have been formulated and launched by the Central Committee of the Communist of China and the State Council, which is of great significance in facilitating the building of a healthy China, completing the process of building a moderately well-off society in all aspects. In view of the status of domestic chronic disease management and the existed challenges (related programs need to be further developed although some achievements have been made in chronic disease management, lack of a scientific chronic disease management system and a scientific, reasonable and effective chronic disease management evaluation system), based on the review of the status of chronic disease management in foreign countries, from a perspective of customer relationship management (CRM), we developed a chronic disease management system (including information subsystem of chronic disease patients, network-based chronic disease management service subsystem, chronic disease management evaluation subsystem), hoping to improve the domestic chronic disease management (including the management quality and efficiency), and to provide a theoretical basis for policy-makers to formulate targeted policies for precision poverty alleviation.