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Previous evidence has showed that telemonitoring blood pressure is helpful to improve the control rate. Here we describe a home telemonitoring model for the management of community-based hypertensive patients with integrating primary care physicians (PCPs) and cardiology specialists in China, planning to screen all residents and manage hypertensive patients individually across the whole course.In community health centers, all residents were measured office blood pressure (BP) and 24-hour ambulatory blood pressure monitoring (ABPM) at baseline. Diagnosed hypertensive patients further received Home Blood Pressure Monitoring (HBPM) devices and were required to measure home BP at least once a week and participate in community-organized activities of hypertension knowledge and healthy lifestyle education. The ABPM and HBPM values were automatically and immediately transmitted once measured through the mobile Internet to Hypertension Management Cloud Platform which stored and analyzed the data shared with PCPs and cardiologists to determine the optimal approaches. The platform also supported timely patient-provider interaction and provided personalized feedback for patients.From February 2017 to March 2018, 28289 patients participated in the model from 32 community health centers in Guiyang, Guizhou province. The average HBPM readings were 2.5 and physician-patient interactive communication online 1.1 per week. The mean BP was reduced by 2.0/2.3 mmHg and control rate increased from 20.4% to 35.8%. Patient hypertension awareness and drug compliance were both markedly improved.The home telemonitoring-based model connecting PCPs and cardiology specialists is feasible to improve the management of hypertension and will extends the primary care to more hypertensive patients.