The research formed an intervention team comprising 1 project leader, 2 project members, 1 community general practitioner, and 3 community nurses. The project leader oversees the project's progress and quality, while the project members implement specific intervention measures. The community general practitioner addresses the health issues faced by patients in their daily lives, and the nurses communicate with both patients and project team members. The intervention is executed on-site and online, with online efforts primarily utilizing WeChat, a widely used social tool in China. The research will span 6 months, with data collection occurring at baseline, 3, and 6 months.

According to the Basic Public Health Service Specification of China and the Prevention and Control Management Guidelines for Hypertension and Diabetes in Primary Health care, routine community care for HP and T2DM patients should be conducted, including monitoring blood pressure and blood sugar, follow-up on the health status of patients, and distribution of community health promotion materials.

Nudge interventions are developed based on the scoping review and qualitative research by the research team, which involves commitment (behavioral contracts), norms (case and experience sharing), significance and framing effects (posters, health behavior identification posts), reminders, and incentives (arteriosclerosis detection). The content encompasses diet, physical activity, medication management, self-monitoring, and control of smoking and alcohol. From the viewpoint of bounded rationality in behavioral economics, and drawing on prior research that has pinpointed decision-making biases in patients' self-management behaviors, nudging strategies have been developed to assist individuals in overcoming these biases or to utilize the patterns of these biases to steer them toward making choices that are in line with their health.

The self-management behaviors of T2DM patients were evaluated using the Diabetes Self-Care Scale (DSCS), encompasses six dimensions: dietary control, regular exercise, medication adherence, blood glucose monitoring, foot care, and management of high/low blood sugar, consisting of a total of 26 items rated on a 5-point Likert scale, with higher total scores reflecting greater levels of the behaviors. The self-management behaviors of hypertensive patients were assessed using the Chinese Self-Management Behavior Assessment Scale for Hypertensive Patients, which includes six dimensions and 33 items: exercise management, health monitoring, work and rest management, emotional management, medication management, and dietary management, all rated on a 5-point Likert scale, with a minimum score of 33 and a maximum of 165. The higher scores mean a better outcome. These scales are answered by patients according to their actual situation.

The Barthel Index (BI) is a widely used assessment tool for evaluating Activity of Daily Living (ADL), distinguishing individual self-care abilities based on the score. This score encompasses bowel movements, urination, grooming, eating, toileting, transferring, mobility, dressing, climbing stairs, and bathing, with a maximum score of 100. A score of 100 signifies excellent daily living ability without reliance on others; scores above 60 are classified as good, indicating mild functional impairment but sufficient self-care in daily living; scores between 60 and 41 reflect moderate functional impairment with some assistance required; scores between 40 and 21 denote severe functional impairment with considerable dependence on others; scores below 20 indicate complete disability with total reliance on others for daily living. This measurement is assessed during the interaction between the researcher and the participant.