隨著慢性病人口快速上升，單一疾病導向的照護模式已難以回應現代醫療需求。糖尿病、慢性腎臟病與心血管疾病三者在病理與照護歷程上相互交織，極需以跨專業整合照護之共照模式加以因應。本文以臺北醫學大學新國民醫院推行之「糖腎心共照模式」為核心，說明如何透過診間整合照護，進一步延伸至社區健康支持系統，並與環境、社會與治理(Environmental, Social, and Governance, ESG)理念相結合，建構永續健康治理之實踐架構。文章聚焦於整合式糖腎心共照流程的建構、社區導向之照護永續機制，以及ESG觀點下的健康治理實踐，並透過制度設計、科技應用與人本關懷並行，勾勒以人為本之慢性病整合照護新典範。

With the rapid rise in chronic disease prevalence, single-disease-oriented care models are no longer sufficient to meet the demands of modern healthcare. The interrelated pathophysiology of diabetes, chronic kidney disease, and cardiovascular disease calls for an integrated, multidisciplinary approach–referred to as a co-care model. This article centers on the implementation of an integrated「Cardiovascular–Kidney–Metabolic (CKM) Co-Care」 model at Taipei Medical University–Hsin Kuo Min Hospital. It explores how clinical care integration can be extended into community-based health support systems, ultimately aligning with the principles of Environmental, Social, and Governance (ESG) for sustainable health governance. We propose three core frameworks, including an integrated co-care pathway for diabetes, chronic kidney disease, and cardiovascular disease, a community-based sustainable care mechanism, and ESG-oriented practices in health system governance. Through institutional design, digital innovation, and human-centered care, this framework seeks to establish a new paradigm for person-centered chronic disease management.