We propose a system-integrated technology-enabled model of care (SINEMA) model. The model, cognizant of health system's organization around tertiary, secondary, and primary levels in China, adopts the principles of cascade training with feedback and task-sharing, and relies on existing human resources available at the community level. It also proposes the use of innovative mobile technology as tools (Android-based smartphone application for VDs and text/voice messages for patients), with the overarching aim of providing evidence-based and essential patient management focusing on medication adherence and physical activity.